Budd-Chiari syndrome: a focussed and collaborative approach. Hepatol Int. 2018;12:483-486. [PMID: 30298269 DOI: 10.1007/s12072-018-9900-z]

Liver Transplantation for Budd-Chiari Syndrome From Myeloproliferative Neoplasms - Management and Long-Term Results

Myeloproliferative neoplasms can cause primary Budd-Chiari-Syndrome with acute or chronic liver failure necessitating liver transplantation. However, preventing the recurrence remains challenging and the need for post-transplant anticoagulant and cytoreductive treatment is not sufficiently clear. We analyzed the treatment regimens for all patients who presented to our department with PBCS from MPN between 2004 and 2021. Eight patients underwent liver transplantation - 6 of them due to an acute liver failure. Post-transplant, all patients received anticoagulant and 7 patients cytoreductive medication. The mean survival after transplantation was 13.25 years. Liver transplantation shows favorable long-term outcome when combined with post-transplant anticoagulant and cytoreductive treatment.

WFUMB Guideline/Guidance on Liver Multiparametric Ultrasound: Part 1. Update to 2018 Guidelines on Liver Ultrasound Elastography

The World Federation for Ultrasound in Medicine and Biology (WFUMB) endorsed the development of this document on multiparametric ultrasound. Part 1 is an update to the WFUMB Liver Elastography Guidelines Update released in 2018 and provides new evidence on the role of ultrasound elastography in chronic liver disease. The recommendations in this update were made and graded using the Oxford classification, including level of evidence (LoE), grade of recommendation (GoR) and proportion of agreement (Oxford Centre for Evidence-Based Medicine [OCEBM] 2009). The guidelines are clinically oriented, and the role of shear wave elastography in both fibrosis staging and prognostication in different etiologies of liver disease is discussed, highlighting advantages and limitations. A comprehensive section is devoted to the assessment of portal hypertension, with specific recommendations for the interpretation of liver and spleen stiffness measurements in this setting.

Budd-Chiari syndrome in children: Challenges and outcome

Budd-Chiari syndrome (BCS) is an uncommon disease of the liver, characterised by obstruction of the hepatic venous outflow tract. The etiological spectrum of BCS as well as venous obstruction pattern show wide geographical and demographic variations across the globe. Compared to adults with BCS, children have primary BCS as the predominant etiology, earlier clinical presentation, and hence better treatment outcome. Underlying prothrombotic conditions play a key role in the etiopathogenesis of BCS, though work-up for the same is often unyielding in children. Use of next-generation sequencing in addition to conventional tests for thrombophilia leads to better diagnostic yield. In recent years, advances in radiological endovascular intervention techniques have revolutionized the treatment and outcome of BCS. Various non-invasive markers of fibrosis like liver and splenic stiffness measurement are being increasingly used to assess treatment response. Elastography techniques provide a novel non-invasive tool for measuring liver and splenic stiffness. This article reviews the diagnostic and therapeutic advances and challenges in children with BCS.

Molecular Mechanisms Underlying Vascular Liver Diseases: Focus on Thrombosis

Vascular liver disorders (VLDs) comprise a wide spectrum of clinical-pathological entities that primarily affect the hepatic vascular system of both cirrhotic and non-cirrhotic patients. VLDs more frequently involve the portal and the hepatic veins, as well as liver sinusoids, resulting in an imbalance of liver homeostasis with serious consequences, such as the development of portal hypertension and liver fibrosis. Surprisingly, many VLDs are characterized by a prothrombotic phenotype. The molecular mechanisms that cause thrombosis in VLD are only partially explained by the alteration in the Virchow's triad (hypercoagulability, blood stasis, and endothelial damage) and nowadays their pathogenesis is incompletely described and understood. Studies about this topic have been hampered by the low incidence of VLDs in the general population and by the absence of suitable animal models. Recently, the role of coagulation imbalance in liver disease has been postulated as one of the main mechanisms linked to fibrogenesis, so a novel interest in vascular alterations of the liver has been renewed. This review provides a detailed analysis of the current knowledge of molecular mechanisms of VLD. We also focus on the promising role of anticoagulation as a strategy to prevent liver complications and to improve the outcome of these patients.

Quantitative liver magnetic resonance imaging: correlation between conventional magnetic resonance imaging, laboratory values, and prognostic indices in Budd-Chiari syndrome

PURPOSE

In Budd-Chiari syndrome (BCS), unevenly distributed parenchymal changes and perfusion abnormalities occur due to hepatic venous outflow obstruction. This study aimed to evaluate the changes in the liver parenchyma in BCS using the quantitative magnetic resonance (MR) techniques of MR elastography, T1 and T2 mapping, and diffusion imaging and correlate the quantitative MR parameters through biochemical results and prognostic indices.

METHODS

Fourteen patients with BCS (seven men and seven women) were examined retrospectively. Liver stiffness (kPa), T1 relaxation times (ms) were achieved using the modified Look-Locker inversion recovery (MOLLI) 3(2)3(2)5 sequence and B1-corrected variable flip angle methods, T2 relaxation times (ms), and apparent diffusion coefficient (ADC) values (mm2/s) were measured using regions of interest placed in the same region in all quantitative methods. Measurements were repeated at the precontrast and postcontrast hepatobiliary phases. The reduction rate (RR; %) and adjusted postcontrast T1 (%) were calculated. The values obtained from different liver parenchyma areas (whole liver, caudate lobe, pathological T2 hyperintense tissue, and relatively preserved normal-appearing tissue) were compared using the Wilcoxon signed-rank test. Spearman's correlation coefficient was used to investigate the correlation between quantitative MR parameters and biochemical parameters/ prognostic scores (Child-Pugh score, Clichy score, and Rotterdam index).

RESULTS

The parenchymal stiffness and precontrast T1 values of the caudate lobe were significantly lower than those of the remainder of the parenchyma, whereas the adjusted postcontrast T1 percentages (MOLLI) were significantly higher (P ≤ 0.027). The parenchymal stiffness value, T1 and T2 values, percentages of RR (MOLLI), and adjusted postcontrast T1 values for the pathological tissue and relatively normal tissue were significantly different (P < 0.028). No significant difference was found in terms of ADC values between any of the distinct regions of the liver. A strong correlation was detected between the Child-Pugh score, Clichy score, and precontrast T1 values obtained through the MOLLI sequence (r = 0.867, P = 0.012, r = 0.821, P = 0.023, respectively). No correlation was found between the whole liver stiffness values and the laboratory parameters, fibrosis markers, prognostic indices, or MR parameters. A significant correlation was identified between creatinine levels and several T1 parameters and the T2 relaxation time (r ≥ 0.661, P ≤ 0.052).

CONCLUSION

Tissue stiffness and T1 relaxation values are high in the areas identified as fibrosis compared with those in the relatively preserved parenchyma. The T1 relaxation time can offer quantitative information for assessing segmental functional changes and prognosis in BCS.ion for assessing segmental functional changes and prognosis in BCS.

Management of splanchnic vein thrombosis

The expression splanchnic vein thrombosis encompasses Budd-Chiari syndrome and portal vein thrombosis. These disorders have common characteristics: they are both rare diseases which can cause portal hypertension and its complications. Budd-Chiari syndrome and portal vein thrombosis in the absence of underlying liver disease share many risk factors, among which myeloproliferative neoplasms represent the most common; a rapid comprehensive work-up for risk factors of thrombosis is needed in these patients. Long-term anticoagulation is indicated in most patients. Portal vein thrombosis can also develop in patients with cirrhosis and in those with porto-sinusoidal vascular liver disease. The presence and nature of underlying liver disease impacts the management of portal vein thrombosis. Indications for anticoagulation in patients with cirrhosis are growing, while transjugular intrahepatic portosystemic shunt is now a second-line option. Due to the rarity of these diseases, studies yielding high-grade evidence are scarce. However, collaborative studies have provided new insight into the management of these patients. This article focuses on the causes, diagnosis, and management of patients with Budd-Chiari syndrome, portal vein thrombosis without underlying liver disease, or cirrhosis with non-malignant portal vein thrombosis.

Role of Inferior Vena Cava (IVC) Recanalization in Patients with Back Pain, Secondary to IVC Obstruction in Budd-Chiari Syndrome

PURPOSE

To study the prevalence of back pain in patients of Budd-Chiari syndrome (BCS) with inferior vena cava (IVC) obstruction, and to evaluate the role of IVC recanalization in resolution of back pain.

METHODS

All patients with BCS and IVC obstruction who underwent IVC recanalization between January 2018 and October 2022 were included. Patients with degenerative spine disease or other identifiable causes for back pain were excluded; remaining patients were assessed for the presence of back pain. In patients with back pain, pain relief was assessed at 24 h following IVC recanalization.

RESULTS

Fifty-eight patients with BCS and IVC occlusion were identified, of which six with degenerative spine diseases were excluded. Of the remaining 52 patients, 34 (65.4%) had back pain, with pain score between 3 and 9. Engorged epidural venous plexus on preprocedural imaging (p = 0.002), and degree of luminal narrowing (p = 0.021) had a significant association with back pain. Twenty-nine of thirty-four patients (85.3%) with back pain had pain relief immediately following IVC recanalization, more so in patients with engorged epidural venous plexus on preprocedural imaging (p < 0.001).

CONCLUSION

Back pain is one of the under-reported symptoms of IVC obstruction in BCS. IVC recanalization by IVC angioplasty with or without stenting relieves back pain due to the decompression of engorged epidural veins.

Indian College of Radiology and Imaging Evidence-Based Guidelines for Interventions in Portal Hypertension and Its Complications

Portal hypertension is a complication of chronic liver disease. Various radiological interventions are being done to aid in the diagnosis of portal hypertension; further, an interventional radiologist can offer various treatments for the complications of portal hypertension. Diagnosis of portal hypertension in its early stage may require hepatic venous pressure gradient measurement. Measurement of gradient also guides in diagnosing the type of portal hypertension, measuring response to treatment and prognostication. This article attempts to provide evidence-based guidelines on the management of portal hypertension and treatment of its complications.

First Report of Fulminant Budd-Chiari Syndrome Treated by Direct Intrahepatic Portocaval Shunt in Vietnam

Budd-Chiari syndrome (BCS) is a rare disorder caused by hepatic venous outflow obstruction that can lead to acute liver failure proposing liver transplantation or transjugular intrahepatic portosystemic shunt. However, the transjugular intrahepatic portosystemic shunt is not always successful due to the entire hepatic vein thrombosis while transplantation is not unfailingly feasible. In these situations, the direct intrahepatic portosystemic shunt (DIPS) is a viable alternative that may ameliorate portal hypertension in these patients. We described a case of a 21-year-old male with fulminant hepatic failure owning to BCS with a 4-day history of abdominal pain and nausea. Laboratory workup, including viral, autoimmune etiologies JAK2 mutation, Factor V Leiden, antiphospholipid antibody syndrome, was negative. The patient's clinical status worsened with hepatic encephalopathy stage II despite administering anticoagulation. Thus, the patient underwent urgently DIPS after unaccessible to the creation of a transjugular intrahepatic portosystemic shunt and impossible to transplantation. The patient's health was improved and discharged. Fulminant Budd-Chiari is a rare disease to be demanding prompt treatment. While transplantation or transjugular intrahepatic portosystemic shunt is failed, the DIPS is considered an alternative candidate associated with clinical improvement.

Diagnosis and therapy of Budd Chiari syndrome

Budd-Chiari syndrome is described as a disorder characterized by the obstruction of hepatic venous outflow. The first description of the syndrome was done by George Budd in 1846. The etiology of the disease is multifactorial and requires differential diagnosing. The prognostic evaluation of patients with liver outflow obstruction differentiates special groups for further treatment procedures. The stepwise approach of Budd-Chiari syndrome allows the finding of the right technique on an individual basis for every patient.

Transjugular intrahepatic portosystemic shunt for Budd-Chiari syndrome: A comprehensive review

Budd-Chiari syndrome (BCS) is a relatively rare clinical condition with a wide range of symptomatology, caused by the obstruction of the hepatic venous outflow. If left untreated, it has got an high mortality rate. Its management is based on a step-wise approach, depending on the clinical presentation, and includes different treatment from anticoagulation therapy up to Interventional Radiology techniques, such as transjugular intrahepatic portosystemic shunt (TIPS). TIPS is today considered a safe and highly effective treatment and should be recommended for BCS patients, including those awaiting orthotopic liver transplantation. In this review the pathophysiology, diagnosis and treatment options of BCS are presented, with a special focus on published data regarding the techniques and outcomes of TIPS for the treatment of BCS. Moreover, unresolved issues and future research will be discussed.

Inferior vena cava obstruction in Budd-Chiari syndrome: a comparative study of rapid quantitative phase-contrast MRI and MRV

PURPOSE

The purpose of this study was to analyze inferior vena cava (IVC) obstruction in Budd-Chiari syndrome (BCS) using rapid quantitative phase-contrast (PC) magnetic resonance (MR) imaging and compare the diagnostic efficacy of PC and MR venography (MRV) to explore the clinical prospects of applying PC quantitative diagnosis in IVC obstruction in BCS.

MATERIALS AND METHODS

PC quantitative data and MRV qualitative data obtained in 35 DSA-recognized inferior vena cava obstruction in BCS patients and 35 patients with liver focal lesions found in physical examination were analyzed and compared.

RESULTS

The areas under the ROC curve for diagnostic parameters related to PC quantitative parameters, including stroke volume, forward flow volume, absolute stroke volume, mean flux, stroke distance, mean velocity (MV), and peak velocity, were 0.7767, 0.7788, 0.7747, 0.7665, 0.9143, 0.9159, and 0.8947, respectively. The sensitivity, specificity, and accuracy of MV in the diagnosis of IVC obstruction were 88.57%, 85.71%, and 87.14%, respectively. For IVC obstruction in BCS, there was no significant difference between the diagnostic efficacy of MV (one of the quantitative parameters of PC) and that of MRV (P = 0.0768).

CONCLUSION

PC can be used to diagnose IVC obstruction in BCS and improve the understanding of hemodynamics of IVC obstruction in BCS.

Retinal vasculitis and skin ulcer preceding Budd–Chiari syndrome in a patient with Behcet's disease

Behcet's disease (BD) is a multisystem disorder with a classical triad of recurrent oral ulcers, genital ulcers, and uveitis. It involves both arterial and venous system which can lead to life-threatening complications. Both superficial and deep venous systems can be involved leading to peripheral skin lesions and devastating complications like cerebral venous thrombosis and Budd–Chiari syndrome (BCS). This report describes a case of an HLA B-52 positive BD in a 22-year-old woman who presented with retinal vasculitis and venous ulcer on the foot and later on developed ascites due to obstruction of supra-hepatic inferior vena cava (BCS). This report highlights the fact that BCS can develop in patients of BD and every ophthalmologist should be aware of this life-threatening complication while they are treating these patients, as timely diagnosis and intervention can prevent mortality.