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Skin Signs of Gastrointestinal Disease

»	List some of the hallmark skin signs seen with diseases of the digestive tract.
»	What is jaundice (icterus) and when is it apparent in the skin?
»	What can a jaundice color spectrum tell me about the types of liver disease in a patient?
»	List the top ten skin findings suggestive of hepatic and biliary tract disease.
»	What is the most common skin symptom associated with liver disease?
»	What diseases associated with intestinal bleeding may also leave clues in the skin?
»	What is pyoderma gangrenosum?
»	A patient presents with anemia, blood in the stool, and red macules on his lips/tongue. What diagnosis should I first consider?
»	What other diagnoses should I consider when seeing a patient with macules on the lips?
»	What is the best treatment for patients with Peutz-Jeghers syndrome?
»	What is pseudoxanthoma elasticum (PXE)? How does this cause GI bleeding?
»	What is Gardner’s syndrome?
»	How can cancer of the gastrointestinal tract present in the skin?
»	What is “malignant” acanthosis nigricans (AN)?
»	What is superficial migratory thrombophlebitis (SMT)?
»	How is inflammation of the fat (panniculitis) associated with pancreatic disease?
»	What chronic liver disease associated with photosensitivity causes blistering and scarring of the skin?
»	What chronic skin disease is associated with a gluten-sensitive enteropathy?
»	How is dermatitis herpetiformis treated?

List the top ten skin findings suggestive of hepatic and biliary tract disease.

Jaundice
Pigment changes
Spider angioma
Palmar erythema
Dilated abdominal wall veins

Purpura
Loss of body hair
Gynecomastia
Peripheral edema
Non-palpable gallbladder

Hepatobiliary diseases are associated with alterations of the vasculature, including spider angiomas, palmar erythema, and cutaneous varices. Spider angiomas are classically associated with chronic liver disease, yet may

Fig. 37.1 Profile view showing dilation of the umbilical vein in the epigastrium. Enlarged abdominal wall veins reflect portal venous hypertension. The patient also had esophageal varices.

also be seen in pregnancy, oral contraceptive use, and in normal persons, especially children. The vascular spider consists of a coiled central arteriole with smaller vessels radiating outward like the legs of a spider. In chronic liver disease, they are numerous and are found on the face, neck, upper chest, hands, and forearms. “Liver palms” refers to the mottled erythema and increased warmth of the palms (and sometimes the soles of the feet) in chronic liver disease. Palmar erythema also may be seen in pregnancy, lupus erythematous, pulmonary disease, and hyperthyroidism.

Portal venous hypertension due to chronic liver disease leads to the development of collateral circulation, with esophageal varices as an example. In the skin, this is observed as dilation of the abdominal wall veins (Fig. 37-1). Caput medusa refers to the dilated periumbilical veins and has been known for centuries as a marker of advanced liver disease. In men with chronic liver disease, induction of a “hyperestrogen state” (due to a decreased efficacy of estrogen breakdown in the liver) leads to gynecomastia, testicular atrophy; loss of axillary, truncal, and pubic hair; and a female pattern of pubic hair. Purpura, ecchymoses, and gingival bleeding reflect impaired hepatic production of various clotting factors, especially the vitamin K–dependent factors. Peripheral edema and ascites indicate hypoalbuminemia and/or portal venous hypertension.