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CASE REPORT
A 86-year-old man presented to the emergency department with progressive dyspnoea, peripheral oedema and a black umbilicus that had developed the week before. He had a three-year history of non-alcoholic steatohepatitis liver cirrhosis and a two-year history of multifocal, incurable hepatocellular carcinoma (HCC) for which an expectant management was chosen. Several months prior to the current presentation he underwent surgery with a mesh repair because of a strangulated umbilical hernia. Physical examination showed a moderately ill patient with jaundice but no signs of encephalopathy, decreased breath sounds at the right lung base, mild abdominal distension without shifting dullness and bilateral lower extremity pitting oedema. Furthermore, we noticed a demarcated dark discoloration without palpable abnormalities of the umbilicus (figure 1). Laboratory data showed marked progression of the liver enzymes with a bilirubin of 310 µmol/l, gamma-glutamyl transpeptidase 239 U/l, alkaline phosphatase 491 U/l, aspartate aminotransferase 72 U/l, alanine aminotransferase 79 U/l and lactate dehydrogenase 257 U/l. Albumin was 24 g/l and the prothrombin time was 12 seconds, creatinine was elevated but stable at 205 µmol/l.
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