Clatworthy's Sign

Abstract

A valuable roentgenographic sign—anterior displacement of the duodenum in a patient with portal hypertension—has been described by surgeons (1) and apparently gone unnoticed. An appropriate case and a well read colleague (2) called our attention to the finding which we term “Clatworthy's sign.” Case Report This 6-year-old white girl had required exchange transfusions for erythroblastosis in the neonatal period. The umbilical vein had been used until it became unsatisfactory, and transfusion was completed through the femoral vein. Abdominal swelling was first noted at eight months of age, but definite ascites was never demonstrated. Subsequently, the child did fairly well but was seen at the University of Colorado Medical Center at the age of six years because of chronic diarrhea and frequent upper respiratory infections. Fibrocystic disease was ruled out by appropriate tests, but an upper gastrointestinal examination revealed esophageal varices, splenomegaly, and anterior displacement of the duodenum. Two months later, the first episode of hematemesis occurred. A repeat barium meal examination confirmed the previous findings (Fig. 1). A splenoportogram demonstrated a thread-like obstructed splenic vein with collateral runoff via the ascending vertebral plexus (Fig. 2). Laparotomy was performed and a shunting procedure attempted, but no adequate portal vessel could be found. The vena cava was buried in a “woody” retroperitoneal space, thick with edematous fibrous tissue and large lymph nodes. A splenectomy was performed. The spleen and four retroperitoneal lymph nodes and surrounding connective tissue were submitted to Dr. R. M. Mulligan of the Department of Pathology, who found congestive splenomegaly, including a weight of 245 g, biphasic active lymphoid nodules, and red pulp cords thickened with reticulum fibers. The lymph nodes revealed no diagnostic features. Subsequently, the patient has required iron replacement therapy for mild chronic gastrointestinal blood loss. Discussion The neonatal transfusions apparently contributed to an omphalitis which led to portal vein thrombosis. Roentgenographic evidence of esophageal varices and a large spleen suggested the diagnosis, and the splenoportogram confirmed the extrahepatic location of the obstruction. Rather massive, poorly controlled hematemesis demanded an attempt at a shunting procedure despite the positive Clatworthy sign—anterior displacement of the duodenum in a patient with portal hypertension. This sign indicates retroperitoneal edema and suggests that collateral circulation is as yet poorly established. We are prone to equate anterior displacement of the duodenum with the presence of a discrete retroperitoneal mass, and consequently to think in terms of pancreatic neoplasm or pseudocyst, lymphoma, neuroblastoma, etc.