A fatal case of Behcet's disease

We report the case of a 32-year-old man with new diagnosed Behcet's disease (BD) with cardiac, central nervous system and vascular involvement. Transthoracic echocardiography disclosed a thrombus in the right ventricle and another thrombus in the inferior vena cava (IVC). The color Doppler imaging was compatible with Budd-Chiari syndrome. Magnetic resonance imaging (MRI) of the brain revealed atrophy of brain stem and right hemisphere and a milimmetric lacunar infarct. Although therapy with urokinase, pulse methylprednisolone and cyclophosphamide was administered immediately, the patient died due to hepatic failure. BD should always be considered in the differential diagnosis of thromboses in the young and thrombotic events should be evaluated during the clinical course of BD.

Radiological interventions in HVOTO--practical tips

Hepatic venous outflow tract obstruction (HVOTO) comprises of constellation of disorders causing obstruction of hepatic venous outflow or suprahepatic inferior vena cava (IVC) or both and leading to increased hepatic sinusoidal pressure and portal hypertension. Clinical presentation in HVOTO includes both acute onset or chronic insidious onset of the disease and predominant clinical manifestations consist of ascites, hepatomegaly, and portal hypertension. IVC/hepatic vein (HV) web or thrombosed hepatic veins replaced by fibrotic constriction or thrombus in suprahepatic IVC is encountered as the pathogenic process at such obstructions. Due to advances in radiologic techniques there has been a changes in the management protocol of HVOTO with surgery or liver transplantation reserved for patients not suitable for radiological interventions or requiring liver transplantation. The present article reviews the techniques of various radiological interventions in HVOTO and their efficacy.

Budd-Chiari syndrome--a review of the diagnosis and management

Budd-Chiari syndrome (BCS) is the liver disease resulting from hepatic venous outflow obstruction comprising a triad of abdominal discomfort, hepatomegaly and ascites. Advances in the management of this disorder over the last three decades have dramatically improved survival. We present a review of the management of BCS followed by a case which illustrates some key points in the diagnosis and treatment of this condition.

Presentation of hospital outcomes and different treatment methods of patients with budd-Chiari syndrome: a report from two tertiary hospitals in iran

OBJECTIVE

The aim of this study was to report common presentations of Budd-Chiari syndrome (BCS) and the early outcome of different treatment methods in two tertiary hospitals in Iran.

SUBJECTS AND METHODS

This case series study was performed on 21 patients (mean age: 42 ± 13.09 years; 11 male, 52.4%, and 10 female, 47.6%) admitted for treatment of BCS in two tertiary referral centers in Mashhad, Iran, between 2002 and 2008. All required data of signs, underlying etiology, treatment methods and in-hospital mortality were gathered from patients' medical records.

RESULTS

Angiographic and sonographic findings showed that the most frequent isolated location of obstruction was the inferior vena cava (n = 12, 57.1%). No distinct underlying disease was found in 6 (28.6%) patients. Eleven (52.4%) patients had web obstruction and 4 patients had other related underlying diseases. Treatment modalities consisted of medical follow-up in 12 (57.1%), angioplasty in 6 (28.6%), and surgery in 3 (14.3%) patients. Medical follow-up of 3 patients, 1 with angioplasty and 2 who had undergone surgery, disclosed that they had died before discharge from hospital.

CONCLUSION

Higher age at diagnosis may reflect late diagnosis at an advanced stage of disease. We suggest that the early symptoms of this disease should be taken into account more seriously in differential diagnosis. Balloon angioplasty seems to be a more efficient method for treatment of BCS.

Splanchnic vein thrombosis: clinical presentation, risk factors and treatment

The term splanchnic vein thrombosis encompasses Budd-Chiari syndrome (BCS), extrahepatic portal vein obstruction (EHPVO), and mesenteric vein thrombosis; the simultaneous involvement of additional regions is frequent, and clinical presentations and risk factors may be shared. The annual incidence of BCS and isolated mesenteric vein thrombosis is less than one per million individuals, while the incidence of EHPVO is about four per million; autopsy studies, however, suggest higher numbers. Current advances in non-invasive vascular imaging allow for the identification of chronic or asymptomatic forms. Risk factors can be local or systemic. A local precipitating factor is rare in BCS, while it is common in patients with portal vein thrombosis. Chronic myeloproliferative neoplasms (MPN) are the leading systemic cause of splanchnic vein thrombosis, and are diagnosed in half the BCS patients and one-third of the EHPVO patients. The molecular marker JAK2 V617F is detectable in a large majority of patients with overt MPN, and up to 40% of patients without overt MPN. Inherited thrombophilia is present in at least one-third of the patients, and the factor V Leiden or the prothrombin G20210A mutations are the most common mutations found in BCS or EHPVO patients, respectively. Multiple factors are present in approximately one-third of the patients with BCS and two-thirds of the patients with portal vein thrombosis. Immediate anticoagulation with heparin is used to treat patients acutely. Upon clinical deterioration, catheter-directed thrombolysis or transjugular intrahepatic portosystemic shunt is used in conjunction with anticoagulation. Long-term oral anticoagulation with vitamin K-antagonists (VKA) is recommended in all BCS patients, and in the patients with a permanent prothrombotic state associated with an unprovoked EHPVO. In patients with an unprovoked EHPVO and no prothrombotic conditions, or in those with a provoked EHPVO, anticoagulant treatment is recommended for a minimum of 3-6 months.

The role of intravascular intervention in the management of Budd-Chiari syndrome

OBJECTIVE

To evaluate the efficacy of intravascular intervention in the management of different types of Budd-Chiari syndrome.

METHODS

Fifty-three patients of BCS were clinically diagnosed and interventionally treated in terms of their signs and symptoms of portal hypertension and occlusive inferior vena cava/or hepatic veins with the combination of Doppler ultrasonography, CT scan, and angiography. The interventional methods applied in this study included percutaneous transluminal angioplasty and IVC stent implantation (PTA+IVC stent); transjugular hepatic veno-stent placement (PTA+HV stent) or transjugular transluminal hepatic veno-inferior vena cava stent placement and transcaval transjugular intrahepatic portocaval shunt.

RESULTS

The success rate of intravascular interventional therapy was 92.45% (49/53). After interventional therapy, the patients' pleural effusion, ascites, prominent veins formation of bilateral flanks or backs alleviated, hepatomegaly reduced, and the urinary output increased. The longest follow-up case was 13 years with patent stent. Two patients died of pulmonary embolization or pericardial tamponade during surgery.

CONCLUSION

Intravascular intervention is a safe and effective therapy for most types of BCS.

[Diagnosis, treatment and evolution of the Budd-Chiari syndrome: a single center experience]

INTRODUCTION

The Budd-Chiari syndrome is a low-prevalence disease due to an hepatic outflow obstruction. It is associated with procoagulant status and liver transplantation is one of the therapeutic tools for the treatment.

OBJECTIVE

To evaluate the etiology, presenting form, treatment and evolution of patients with Budd-Chiari syndrome.

PATIENTS AND METHOD

Ten consecutive adult patients with Budd-Chiari syndrome evaluated from January 1998 to June 2009 were prospectively included. The median follow up was 32.4 months (4-108 months).

RESULTS

The mean age of patients was 34 +/- 12 years old. Presentation was acute in 1 patient, chronic in 2 and subacute in 7. The mean time from consultation to diagnosis was 4 +/- 2 days. Clinical manifestations were splenomegaly in 8 patients, malnutrition in 7, ascites in 6 and encephalopathy in 4. Diagnosis was confirmed by angiography in all cases. Initial prothrombin concentration was < 30% in 3 patients, 31% to 50% in 5, and > 50% in 2; hematocrit was > 45% in 5 patients and platelet count was > 400.000/mm3 in 6. MELD distribution at diagnosis was < or = 13 points in 4 patients, between 14 and 16 points in 5 and > or = 17 points in 1. Policytemia vera was detected in 7 patients, essential thrombocythemia in 1 and positive lupus inhibitor in 4. Nine patients were anticoagulated after diagnosis. Angioplasthy was required in 1 patient and 6 were treated with a transjugular intrahepatic portosystemic shunt. Death occurred in 1 patient due to gastrointestinal bleeding. Two patients were transplanted.

CONCLUSION

In our experience all patients with Budd-Chiari syndrome have a procoagulant status. The transjugular intrahepatic portosystemic shunt is effective in treating this syndrome and liver transplantation should be reserved for patients who are refractory to other therapeutics.

Budd-Chiari Syndrome. Changing epidemiology and clinical presentation

Budd-Chiari Syndrome (BCS) is a rare cause of portal hypertension. Geographical variations occur, particularly in the clinical presentation, where there are distinct differences between West and South Asia. Idiopathic forms are common in south Asia, while hypercoagulable disorders are common causes of BCS in the West. The site of thrombosis is also different, with patients from South Asia presenting with combined obstruction of the hepatic veins and the inferior vena cava in contrast to isolated obstruction of the hepatic veins, common in the West. Ultrasound-Doppler studies confirm the diagnosis in the majority. Early radiological interventions, including transjugular intrahepatic portosystemic shunt, can cure the majority of cases with idiopathic forms. Prothrombotic forms are treated with long-term anticoagulants. Surgery is reserved to a selected few with long segment obstruction. Liver transplantation is indicated in patients with worsening clinical functional status not responding to medical and/or interventional management.

Hepatocellular carcinoma with presentation of budd-Chiari syndrome

Budd-Chiari syndrome is defined as hepatic venous outflow obstruction at any level from the small hepatic veins to the junction of the inferior vena cava and the right atrium independent of the underlying disease. We report here a 40-year-old male patient who complained of abdominal fullness and bilateral lower leg edema for 1 month. A physical examination disclosed bilateral lower leg edema. Abdominal sonography revealed a small amount of ascites with thrombosis of the inferior vena cava and right hepatic vein. Viral hepatitis marker tests showed positive hepatitis B surface antigen. Tumor markers showed elevated serum a-fetoprotein levels. Computed tomography and magnetic resonance imaging confirmed hepatocellular carcinoma with inferior vena cava and right hepatic vein thrombosis. Therefore, hepatocellular carcinoma with Budd-Chiari syndrome was diagnosed. The patient was treated with intravenous heparin, which was then changed to oral warfarin. Although it is relatively rare, clinicians should be aware of hepatocellular carcinoma with Budd-Chiari syndrome when leg edema occurs without hypoalbuminemia in patients with chronic hepatitis B, because these patients are in the high-risk group for developing hepatocellular carcinoma. Regular follow-up of chronic hepatitis B, including biochemical and sonography surveillance, should be performed.

[Case report: Budd-Chiari syndrome and esophageal variceal bleeding due to alveolar echinococcosis]

Alveolar echinococcosis of the liver is a rare larval cestode disease which is due to the intrahepatic growth of the tapeworm Echinococcus multilocularis. This cestode naturally evolves as a larval stage within cysts in the body of carnivores. Humans are accidental intermediate hosts and become infected, either by eating food contaminated with carnivore-originated eggs or by touching foxes. It behaves as malignant liver tumour and rarely causes Budd-Chiari syndrome and variceal bleeding. Budd-Chiari syndrome is a hepatic venous outflow tract obstruction and may be present abdominal pain, hepatomegaly and ascites. Parasitic cysts may cause compression and thrombosis of the hepatic venous outflow tract. It may present as portal hypertension and variceal upper gastrointestinal bleeding. We here in report a 47-year-old woman without a prior history of liver disease presented with Budd-Chiari syndrome and variceal bleeding due to Alveolar echinococcosis. The course of this rare disease is demonstrated by means of the most important laboratory, serologic and radiologic parameters.

[A case of chronic Budd-Chiari syndrome]

The Budd-Chiari syndrome is a rare disease associated with occlusion of the hepatic vein by a tumor or a thrombus. It develops due to progressive narrowing or occlusion of the hepatic veins and may occasionally proceed through the chronic disease within months, rarely years as individual recurrences, with pains, enlarged liver, and mild jaundice. These patients generally have partial hepatic vein occlusion. The paper describes a long (more than 20 years) course of the Budd-Chiari syndrome in which only a special angiographic study could verify the presumptive diagnosis and reveal the cause of evolving liver cirrhosis.

[Cyclospora cayetanensis and Cryptosporidium parvum coinfection in a pregnant woman with prolonged diarrhoea]

Cyclospora cayetanensis which is a recently described pathogen, is associated with prolonged diarrheae and history of travelling to tropical regions and intake of suspicious food and water. Cryptosporidium parvum is another pathogen that causes severe diarrhea defined initially in especially AIDS patients since 1980's. Cases of cyclosporiasis are frequently missed, since it is difficult to detect the parasite in human fecal samples, despite an increasing amount of data regarding this parasite. To identify both of these coccidian protozoa, faeces should be examined by modified acid-fast stain. Co-incidence of C. cayetanensis and C. parvum is seen rarely in Turkey. In this case report, C. cayetanensis and C. parvum found in a 28 years old pregnant women living in continental climate and without a history of travel, were presented. The patient had prolonged diarrhea and investigation of the feces by modified acid-fast and carbol fuchsin stains revealed C. cayetanensis and C. parvum. The immunoglobulin and lymphocyte subgroup testing done for the evaluation of the immune status of the patient, were all within normal limits. Following treatment with trimethoprim-sulfamethoxazole for 15 days, the oocyst number in feces has decreased. However, hepatic vein thrombosis and liver failure have developed in the postnatal period and she was diagnosed as Budd-Chiari syndrome. It was concluded that when the effect of pregnancy on immunity was taken into account, C. cayetonensis and C. parvum should be considered in cases of prolonged diarrhoeae in pregnant women.

[Budd-Chiari syndrome and splanchnic vein thrombosis: masked myeloproliferative neoplasms and JAK2V617F]

The Budd-Chiari Syndrome (BCS) and the splanchnic vein thrombosis are characterized by hepatic venous outflow obstruction, generally due to venous thrombosis. These rare diseases are usually caused by multiple concurrent factors, including acquired and inherited thrombophilias. Since the diagnosis of myeloproliferative neoplasms (MPNs) is often difficult in patients with BCS and splanchnic vein thrombosis because of spleen enlargement, secondary pancytopenia and bleeding disorders, recent observations have included in the diagnostic work-up the analysis of the JAK2 mutation. The revision of several recent reports clarify the importance of the JAK2V617F detection in the diagnostic work-up of the BCS and splanchnic vein thrombosis, allowing the demonstration of masked MPNs among these cases that may benefit, in the near future, of target molecular therapies directed toward the JAK2 mutation.

Levels and initial course of serum alanine aminotransferase can predict outcome of patients with Budd-Chiari syndrome

BACKGROUND & AIMS

Patients with Budd-Chiari syndrome can present with acute, subacute, or chronic disease; the definitions and significance of these variants have been disputed. An increased level of serum alanine aminotransferase (ALT) is an objective marker for acute liver injury. We analyzed the significance of changes in ALT levels in Budd-Chiari syndrome patients.

METHODS

We performed a retrospective analysis of data from 96 consecutive Budd-Chiari syndrome patients.

RESULTS

A threshold peak ALT level that was 5-fold the upper limit of normal distinguished 2 groups of patients: patients with high levels of ALT (40% of patients) presented with more severe liver disease, less frequent liver fibrosis, and more frequent liver cell necrosis, compared with those with ALT levels below this threshold. Patients with levels of ALT that started out high but slowly declined (<50% of starting concentration within 3 days) had significantly lower odds of survival than those with a rapid decline and those with low levels of ALT (40 months transplantation-free survival, 31%, 63%, and 71%, respectively). When ALT level and the velocity of its decline are used as criterion, these data add significant prognostic information to Child-Pugh, to Clichy, and to Rotterdam Budd-Chiari syndrome scores.

CONCLUSIONS

Determination of ALT levels at patient presentation allows 2 variants of Budd-Chiari syndrome to be distinguished. High levels of ALT reflect acute, severe, but potentially reversible, ischemic liver cell necrosis. High levels of ALT that decrease slowly predict a poor outcome for patients and might justify rapid aggressive management.

[The Budd-Chiari syndrome and Buerger's disease: a case report]

BACKGROUND

Buerger's disease is an inflammatory non atheromatous distal arteriopathy affecting mainly young male smokers. There is some controversy about the existence of visceral localisations of the disease.

AIM

Report a new case.

OBSERVATION

We report the case of a 40-years-old man who developed a Budd Chiari syndrome with thromboses of the right hepatic venous. Later, he presented with rheumatic and distal occlusive arterial manifestations diagnosed as Buerger's disease.

CONCLUSION

We underline the fact that digestive manifestations and hepatic involvement are less known and sometimes misdiagnosed.

Paroxysmal nocturnal hemoglobinuria in Budd-Chiari syndrome: findings from a cohort study

BACKGROUND/AIMS

A well recognized cause of Budd-Chiari syndrome (BCS) is paroxysmal nocturnal hemoglobinuria (PNH). PNH is an acquired disorder of hematopoietic stem cells, characterized by intravascular hemolysis and venous thrombosis. Testing for this hematological disorder should be considered in all BCS patients.

METHODS

Using data from the EN-Vie study, a multi-center study of 163 patients with BCS, we investigated the relationship between BCS and PNH in 15 patients with combined disease and compared the results to 62 BCS patients in whom PNH was excluded.

RESULTS

Median follow-up for the study group (n=77) was 20 months (range 0-44 months). BCS patients with PNH presented with a significantly higher percentage of additional splanchnic vein thrombosis (SVT) as compared to BCS patients without PNH (47% vs. 10%, p=0.002). During follow-up, type and frequency of interventions for BCS was similar between both groups. Six patients with BCS and PNH were successfully treated with a transjugular intrahepatic portosystemic shunt (TIPS). Of 15 patients with PNH, six underwent allogenic stem cell transplantation after diagnosis of BCS. PNH was successfully cured in five cases. There was no significant difference in survival between BCS patients with and without PNH.

CONCLUSIONS

This study shows that despite a higher frequency of additional SVT, short-term prognosis of BCS patients with PNH does not differ from BCS patients without PNH. Treatment with TIPS can be safely performed in patients with PNH. Stem cell transplantation appears to be a feasible treatment option for PNH in BCS patients.

Budd-Chiari syndrome secondary to polycythemia vera. A case report

Budd-Chiari syndrome still represents a challenge for the hepatologist with regard to its causes and its most effective therapy. Polycythemia vera is considered to be the most frequent condition causing the Budd-Chiari syndrome (10-40% of cases). We present a 34-year-old patient in post-partum who was admitted for right upper abdominal quadrant pain and asthenia. Laboratory data, abdominal echography and angioMRI all raised the suspicion of BCS, but it was in the haematological department that polycytemia vera was diagnosed as the cause of the hepatic condition.

Vascular disorders of the liver

This guideline has been approved by the American Association for the Study of Liver Diseases (AASLD) and represents the position of the association.

Spontaneous regression of Budd-Chiari syndrome (hepatic venous occlusion) in a young female

A case of occlusion of the hepatic veins in an 18-year-old girl is presented. The onset was sudden with massive ascites and markedly impaired general condition. The diagnosis was based on liver biopsy and angiograms of the caval and hepatic veins as well as of the celiac artery. No predisposing factors could be found. The patient was treated conservatively with laparocentesis and diuretics. Clear improvement was seen after two weeks, and after four weeks she had no ascites and could be discharged. All liver function tests were then normalized. After three months, all diuretics could be withdrawn, and in the following 11 years she has remained completely recovered. The case illustrates that also widespread thrombi of the hepatic veins may sometimes rapidly dissolve spontaneously, with apparent total reconstitution of hepatic function. This case is unusual since previously reported cases have had high mortality rates and, in surviving cases, operative procedures or large doses of diuretics have been required to control the ascites.

[Association Budd Chiari syndrome, antiphospholipid syndrome and Grave's disease]

BACKGROUND

Antiphospholipid syndrome is revealed by Budd Chiari syndrome in 5% of the cases. Antiphospholipid syndrome is characterized by venous or arterial thrombosis, foetal loss and positivity of antiphospholipid antibodies, namely lupus anticoagulant, anticardiolipin antibodies and anti-beta2-glycoprotein I. Anticardiolipin antibodies was reported in auto-immune thyroid disorders, particularly in Grave's disease. Antiphospholipid syndrome associated to Grave's disease was reported in only three cases.

AIM

To describe a case report of association of Grave's disease and antiphospholipid syndrome.

OBSERVATION

We report the first case of Grave's disease associated with antiphospholipid syndrome, revealed by Budd Chiari syndrome.

CONCLUSION

Our observation is particular by the fact that it is about a patient presenting a Grave's disease associated with antiphospholipid syndrome revealed by Budd Chiari syndrome. This triple association has never been reported in literature. Although association between antiphospholipid syndrome and Grave's disease was previously described, further studies evaluating the coexistence of these two affections in the same patient would be useful.

[Budd-Chiari syndrome induced by hormonal oral contraception in the patient with congenital thrombophilia-factor V Leiden mutation--a case report]

The Budd-Chiari syndrome is a rare pathology resulting from various etiological factors which often contribute to its late diagnosis. Liver cirrhosis, malignant tumors and haematological disorders resulting in hypercoagulability, are the most common reasons of Budd-Chiari syndrome. The syndrome is characterized by portal hypertension and splanchnic congestion due to obstruction of hepatic venous outflow. The first symptoms include pain, ascites and hepatosplenomegaly. The diagnosis of Budd-Chiari syndrome can be achieved by Doppler ultrasonography, Computed Tomography scan, Magnetic Resonance or Single Photon Emission Computed Tomography. In the following article, a case report of a patient with diagnosed Budd-Chiari syndrome as a result of congenital thrombophilia-factor V Leiden gene mutation is presented. Clinical symptoms, diagnostic process, as well as treatment options, were shown in the article.

[Budd-Chiari syndrome--hematologists' part in the multidisciplinary approach]

Budd-Chiari syndrome presents a serious disease with a complex etiology and clinical manifestations, which is associated with high morbidity and mortality. An early diagnosis and therapy is mandatory due to the severity of disease and therapy contains the treatment of underlying disorder, anticoagulation therapy and therapy of liver impairment. We discuss hematologists' contribution to the diagnostic approach and therapy of this syndrome.