Visualization of caput medusa in a patient with hepatoma

A 70-year-old man presented with a history of alcohol abuse and three prior episodes of bleeding from esophageal varices. On physical examination, he had ascites and a bruit over the right lobe of the liver. A diagnosis of hepatoma was established by needle biopsy. Radionuclide studies demonstrated a photon-deficient region in the liver by Tc-99m sulfur colloid, which picked up Ga-67 citrate. Angiography with Tc-99m labeled RBCs demonstrated an arterioportal fistula and a caput medusa.