It is not limited to the upper trunk. You also see it on the arms, and face, and sometimes elsewhere also. I  have heard that it may be related to increased estrogens in cirrhotic patients.

Dear Sr. Luis thank you!

Dear Sr. Roger, thank you! Yes, on the face, on arms also, but not in the lower part of a body. I have never seen them on an abdomen. Circulation of high level of an oestrogen can explain occurrence of spider angioma. But it doesn't explain their localisation?

Sincerely, Zmicer

The spider angioma basically occurs in relation to the superior vena cava drainage area. 1 to 3 may be normally occurring, but more than 3 are definite pathognomic. Mostly due to cirrhosis, sometimes even in pregnancy.

 The non-metabolized estrogens can get access to systemic circulation through the porto-systemic collaterals developed in portal hypertension and can cause effects on upper trunk, including the arms and may even occur in hands of children.

I think I remember seeing them on the belly - yes.

Spider angiomas occur in regions drained by superior vena cava (face, upper limbs and upper chest); more than three abnormal except in pregnancy

It should be noted that spider angiomas can also be found in locations other than the skin, such as mouth and gastrointestinal tract mucosa.

http://www.ncbi.nlm.nih.gov/pubmed/1936855

http://www.ncbi.nlm.nih.gov/pubmed/11051406

http://www.ncbi.nlm.nih.gov/pubmed/14997143

http://www.ncbi.nlm.nih.gov/pubmed/10881631

Dear Ivanildo:

    Thanks so much! What a nice addition to the topic!

Roger Jelliffe

Spider angiomas on skin correspond to gastropathy, enteropathy, colopathy that occur internally in the GI mucosa in cirrhosis and portal hypertension and the pathogenesis are the same i.e.increased amount of large number of vasodilators in the portal circulation that are not metabolised by the cirrhosed liver. Most probable cause of location in the superior vena cava drainage area in that maximum blood in the portal circulation that cannot go through the liver due to fibrosis reach the systemic circulation through the SVC as has been documented in the pathogenesis of esophageal varices in addition to the vasodilation.

It is a very interesting question, Zmicer. Actually, spider angiomas also called as telangiectasias, are not specific to liver cirrhosis or portal hypertension. Nevertheless, they are frequent (not exclusive) in liver cirrhosis and located on skin and mucosa of superior vena cava territory. It is certain that hyper estrogenic theory of genesis is the most mentioned, however it has never been proved. We can see them all the long of GI tract from mouth to rectum without relation to liver cirrhosis, neither plasma estrogen high levels nor portal hypertension. In these locations they are frequent cause of bleeding and risk factors are genetics, advanced age and renal insufficiency.

My impression concerning pthophysiology of telangiectasias or spider angiomas (including those of liver cirrhosis)  is that these lesions are related to angiogenic factors. Currently there are around 20 that have been identified.i.e. FGF,VEGF,Ang-1 and Ang-2, etc. Here there is a matter of research.

Having more than 3 spider angiomas is likely to be abnormal.

The spider angiomas are found only in the distribution of the superior vena cava, and are thus commonly found on the face, neck, upper part of the trunk and arms.

 upper GI endoscopy shows multiple spider angiomas in the stomach and the duodenum

GI angiomas have nothing to see with chronic liver disease. They frequenly are seen in patients without liver disease.

Pathophysiology is not clear.

I had done an upper GI endoscopy for a patient with liver cirrhosis due to severe anemia. It revealed multiple spider nevi in the stomach and the duodenum. The video is present on my you tube named salem yousef:internal medicine knowledge.  You can check

Dear Salem

I have no doubts about your endoscopy findings in your patient. Nevertheless.  it is not usual in the whole cirrhotic population. Please check prevalence of angiodysplasia in cirrhotic vs non cirrhotic population seen by conventional endoscopy (video capsule and deep enteroscopy) and you will see non-significant difference.  Findings in one patient is not enough for arriving to valid conclusions.

In the opposite side I do not know why telangiectasia are only seen in the vascular territory of superior vena cava. For me is a mystery.

Best regards

Dear prof Diego,

Thanks for your prompt response.  Iam totally agree with you

Dear Salem,

I think what you observed in the stomach is portal hypertensive gastropathy or PHG which is very frequent in cirrhotic patients. 

As regards Prof Diego's comment, I surmise it may be due to the redistribution of the large volume of portal blood into the superior vena cava system in portal hypertension and cirrhosis through collaterls along with the vasodilatation that occurs.