Acute Budd-Chiari syndrome with fulminant hepatic failure in a pregnant woman with factor V Leiden mutation

Outcomes of status 1 liver transplantation for Budd-Chiari Syndrome with fulminant hepatic failure

There is a paucity of data on the outcome of liver transplantation (LT) in Budd-Chiari Syndrome (BCS) patients who are listed as status 1. The objective of our study was to determine patient or graft survival following LT in status 1 BCS patients. We utilized United Network for Organ Sharing (UNOS) database to identify all adult patients (> 18 years of age) listed as status 1 with a primary diagnosis of BCS in the United States from 1998 to 2018, and analyzed their outcomes and compared it to non-status 1 BCS patients. Four hundred and forty-six patients with BCS underwent LT between 1998 and 2018, and of these 55 (12.3%) were listed as status 1. There was no difference in long-term post-liver transplant or "intention-to-treat" survival from the time of listing to death or the last day of follow-up between status 1 and non-status 1 groups. Graft and patient survival at 5 years for status 1 patients were 75% and 82%, respectively. Cox regression analysis showed that patients listed as status 1 (aHR: 0.45, p < .02) were associated with a better survival. BCS patients listed as status 1 have excellent survival following emergency LT.

Acute liver failure in Budd-Chiari syndrome and a model to predict mortality

BACKGROUND AND OBJECTIVE

Acute liver failure (ALF) occurs in approximately 1-2% of patients with Budd-Chiari syndrome (BCS). The primary objective of our study was to study the outcome of patients with BCS-ALF using the National Inpatient Sample (NIS) database and develop a mortality prediction model.

DESIGN

We identified all adult patients with BCS, with and without ALF, using ICD-9 or ICD-10. Using clinical variables, we identified risk factors for in-hospital mortality and developed a prediction model using logistic regression analysis. The model was built and validated in a training and validation datasets.

RESULTS

Between 2008 and 2017, of the estimated total of 5,306 (weighted sample size 26,110) BCS discharges, 325 (6.1%) patients (weighted sample size 1,598) presented with ALF. Of 325 BCS-ALF patients, 114 (34.7%, weighted n = 554) died and in contrast only 267 of 4,981 (5%, weighted n = 1310) without ALF died during the hospitalization. The independent risk factors that predicted mortality were age 50 years or older, acute respiratory failure, spontaneous bacterial peritonitis, sepsis and cancers. The prediction model that incorporated these risk factors had an area under the receiver operating characteristic curve (AUROC) of 0.85 (95% CI 0.80-0.90) for training data and 0.80 (95% CI 0.71-0.89) for validation data. The predicted mortality risk with low (score < 6), intermediate (score 6-16), and high risk (score ≥ 17) scores were 8%, 37% and 71%, respectively.

CONCLUSION

ALF due to BCS is associated with a very high in-hospital mortality that could be predicted with reasonable accuracy.

Budd-chiari syndrome causing acute liver failure: A multicenter case series

Budd-Chiari syndrome (BCS) is a rare disease resulting from obstruction of the hepatic venous outflow tract that typically presents with abdominal pain, jaundice, and ascites without frank liver failure. However, BCS may also evolve more rapidly to acute liver failure (ALF). In this study, we describe the clinical features, treatment, and outcomes of ALF due to BCS and compare our results with those in the published literature. Twenty of the 2344 patients enrolled in the Acute Liver Failure Study Group (ALFSG) registry since 1998 presented with a clinical diagnosis of BCS. An additional 19 patients of ALF-BCS in the English language literature were reviewed and compared with the ALFSG cases. Most ALF-BCS patients were white (84%) and female (84%) in their fourth decade. A hypercoagulable state was noted in 63% of patients. BCS was diagnosed by Doppler ultrasonography or abdominal computed tomography in all patients. Liver biopsies (n = 6) all had evidence of severe pericentral necrosis. Treatments used included most commonly anticoagulation (71%), but also transjugular intrahepatic portosystemic shunt (TIPS; 37%) and orthotopic liver transplantation (37%). In-hospital mortality was approximately 60%. In conclusion, BCS is a rare cause of ALF and mandates prompt diagnosis and management for successful outcomes. Once the diagnosis is confirmed, prompt anticoagulation is recommended in conjunction with evaluation for malignancy or thrombophilic disorder. Mortality may have improved in recent years with use of TIPS and/or orthotopic liver transplantation compared with prior published reports. Liver Transplantation 23 135-142 2017 AASLD.

Gastrointestinal causes of abdominal pain

Gastrointestinal causes of abdominal pain are numerous. These causes are reviewed in brief here, divided into 2 categories: acute abdominal pain and chronic abdominal pain. They are further subcategorized by location of pain as it pertains to the abdomen.

Pregnancy and vascular liver disease

Vascular disorders of the liver frequently affect women of childbearing age. Pregnancy and the postpartum are prothrombotic states. Pregnancy seems to be a trigger for Budd-Chiari syndrome in patients with an underlying prothrombotic disorder. Whether pregnancy is a risk factor for other vascular liver disorders is unknown. In women with a known vascular liver disorder and a desire for pregnancy, stabilisation of the liver disease, including the use of a portal decompressive procedure when indicated, should be reached prior to conception. The presence of esophageal varices should be screened and adequate prophylaxis of bleeding applied in a manner similar to what is recommended for patients with cirrhosis. Most women likely benefit from anticoagulation during pregnancy and the postpartum. Labor and delivery are best managed by a multidisciplinary team with experience in this situation. Assisted vaginal delivery is the preferred mode of delivery. Although the risk of miscarriage and premature birth is heightened, current management of these diseases makes it very likely to see the birth of a live baby when pregnancy reaches 20 weeks of gestation.

Case of Budd-Chiari syndrome 3 months after vaginal delivery

Budd-Chiari syndrome is a rather unusual clinical situation caused by occlusion of the hepatic vein of inferior vena cava, the classical triad of which are abdominal pain, ascites and hepatomegaly. A 29-year-old gravida 3 para 1 woman delivered an immature male baby weighing 2172 g with an Apgar score of 9 points at 35 weeks and 3 days of gestation. She was transferred to the National Hospital Organization Osaka National Hospital 112 days after delivery due to the sudden development of massive ascites. Magnetic resonance angiography and enhanced computed tomography detected the occlusion by thrombosis of both the middle and left hepatic veins, so she was diagnosed with Budd-Chiari syndrome. Her protein C antigen and activity were 37% and 50%, respectively, corresponding to type 1 protein C deficiency. Conservative treatment by continuous oral treatment of spironolactone (25 mg/day), furosemide (20 mg/day) and prophylactic warfarin (2 mg/day) much improved the ascites.

Celiac disease and myointimal proliferation: a possible correlation?

Celiac disease (CD) is an autoimmune disorder of the small bowel that occurs in genetically predisposed people of all ages, from middle infancy, and is caused by a reaction to gliadin, a gluten protein. Some patients are diagnosed with symptoms related to the decreased absorption of nutrients or with various symptoms which, although statistically linked, have no clear relationship with the malfunctioning bowel. Classic symptoms of CD include diarrhea, weight loss, and fatigue; bowel symptoms may be limited or even absent. In this article we describe the case of a young woman with CD who presents with myointimal proliferation. However multiple cases of vessel thrombosis have been reported in patients with CD. Despite the fact that no definitive relationship between these diseases could be explained, we think this association must be remembered especially in cases of young and tenuous women with these vascular abnormalities.

Acute liver failure including acetaminophen overdose

Acute liver failure (ALF) is a dramatic, highly unpredictable clinical syndrome defined by the sudden onset of coagulopathy and encephalopathy. Acetaminophen overdose, the leading cause of ALF in the United States, has a 66% chance of recovery with early N-acetylcysteine treatment and supportive care. Cerebral edema and infectious complications are difficult to detect and treat in these patients and may cause irreversible brain damage and multiorgan failure. One-year survival after emergency liver transplantation is 70%, but 20% of listed patients die, highlighting the importance of early referral of patients who have ALF with a poor prognosis to a transplant center.

Liver transplantation as definitive treatment for a factor V Leiden mutation

Liver transplantation (LT) was achieved for factor V Leiden-induced thrombophilia in a neonate with hepatic veno-occlusive disease. Initial LT was performed with a liver segment removed from a child with primary oxalosis. Four months later, a second, definitive LT was performed. The child remains well without recurrent thrombosis.

Budd-Chiari Syndrome Associated with Visceral Leishmaniasis and Factor V Leiden Mutation

We here report a case of subacute Budd-Chiari syndrome (BCS) related to Factor V Leiden (FVL) mutation in the presence of visceral leishmaniasis. A 17-year-old man was admitted to hospital because of abdominal pain, pretibial edema and fever. The clinical picture of BCS had been developed within several months. BCS was diagnosed by radiographic examination. On DNA analysis, a heterozygote Arg506Gln mutation in the factor V gene was found. Histological examination of the bone marrow showed intracellular leishmania amastigotes. Despite appropriate treatment patient's clinical condition deteriorated rapidly and died with multiorgan failure. FVL mutation is the most common procoagulant disorder and account for many cases of BCS. This case report demonstrates that in addition to duration and severity of the disease accompanying conditions including infections are prognostically significant for the outcome of this potentially lethal disease.

Successful treatment of acute Budd-Chiari syndrome with percutaneous transluminal angioplasty

A 26-year-old man developed progressive, massive ascites and hematemesis due to rupture of esophageal varices. Combination diagnostic modalities of color doppler ultrasonography, enhanced computed tomography, and magnetic resonance imaging led to the case being diagnosed as acute Budd-Chiari syndrome with severe stricture of the intrahepatic inferior vena cava. Percutaneous transluminal angioplasty this resulted in great improvement of the clinical manifestations.

Acute hepatic failure in pregnancy

Severe liver dysfunction in late pregnancy is an unusual but dramatic event because it can progress very rapidly to fulminating disease and also because two lives, that of the mother and foetus, are involved. We report a descriptive study of a pregnant woman presenting with severe liver dysfunction.

Liver transplantation in a patient with Budd-Chiari syndrome secondary to factor V Leiden mutation

A point mutation in the factor V Leiden gene is the most common hereditary thrombophilic state and an important risk factor for Budd-Chiari syndrome. We report on a patient with Budd-Chiari syndrome secondary to factor V Leiden mutation, who underwent successful liver transplantation. Following liver transplantation, his thrombophilic state was corrected and he did not require anticoagulation therapy. There has been no recurrent venous thrombosis for 14 months after transplantation. Although his activated protein C sensitivity was normal, showing the normalization of protein C-factor V interaction, PCR analysis demonstrated that heterozygosity for factor V Leiden mutation was still present. We suggest checking resistance to activated protein C, rather than PCR analysis of factor V Leiden mutation in patients with Budd-Chiari syndrome after liver transplantation; the presence of the second does not effect clinical outcome.

Transatrial Stent Placement for Treatment of Inferior Vena Cava Obstruction Secondary to Extension of Intracardiac Tumor Thrombus from Hepatocellular Carcinoma

Two cases of superior vena cava-to-inferior vena cava (IVC) transatrial stent placement to palliate obstruction of the IVC secondary to the intracardiac extension of hepatocellular carcinoma are reported. Both patients presented with debilitating edema of the trunk and lower extremities and varying degrees of hepatic venous obstruction resulting in Budd-Chiari syndrome. One patient required the adjunctive creation of a percutaneous portocaval shunt and the second patient responded to transatrial stent placement alone. Both patients' functional status improved and edema markedly decreased after endovascular therapy.

Acute Budd-Chiari syndrome during pregnancy: surgical treatment and orthotopic liver transplantation with successful completion of the pregnancy

A 26-year-old woman presented with acute Budd-Chiari syndrome 18 weeks into a pregnancy. She was found to be heterozygous for the G20210A prothrombin gene mutation. She was treated with portacaval shunt placement and successfully completed the pregnancy, with a healthy baby delivered at 31 weeks' gestation. She developed progressive liver failure after delivery of the child, likely associated with clotting of the shunt, which occurred in the face of full anticoagulation. The patient subsequently underwent a technically complicated orthotopic liver transplantation, but died 10 months after transplantation. This case illustrates the challenges involved in the treatment of Budd-Chiari syndrome, in addition to difficulties balancing the health of a mother and an unborn child. It is the only case of surgical treatment of Budd-Chiari syndrome during pregnancy reported in the literature.

Budd-Chiari syndrome: combination of genetic defects and the use of oral contraceptives leading to hypercoagulability

A young female, who had been in excellent health and had used third-generation oral contraceptives, was admitted to hospital because of abdominal pain and ascites. Budd-Chiari syndrome (BCS) was diagnosed by radiographic and histological examination. Tests for myeloproliferative disease, deficiency of coagulation inhibitors and paroxysmal nocturnal haemoglobinuria were negative. DNA investigation showed a double heterozygous defect: the Arg506Gln mutation in the factor V gene (factor V Leiden) and G20210A nucleotide substitution in the prothrombin gene. This double defect was also found in the patient's father, who had never experienced an episode of venous thromboembolism. Genetic and acquired thrombogenic risk factors are being detected increasingly in patients with BCS. With the discovery of new genetic defects leading to hypercoagulabiulity an increasing number of patients with serious thrombotic manifestations, such as BCS, will exhibit concurrence of hereditary and acquired risk factors for thrombosis.

Budd-Chiari syndrome associated with factor V leiden mutation: a report of 6 patients

Budd-Chiari syndrome is characterized by hepatic venous outflow obstruction. Although myeloproliferative disorders are usually responsible for this severe thrombotic disorder, deficiency or dysfunction of the natural anticoagulants can be involved. Resistance to activated protein C caused by factor V Leiden mutation has been recently identified as a major cause of thrombophilia. We report 6 patients with Budd-Chiari syndrome associated with factor V Leiden mutation combined with another acquired thrombophilic state (myeloproliferative disorder and lupus anticoagulant in 3 cases) and without another thrombophilic disorder in the other 3 cases. We conclude that factor V Leiden mutation should be evaluated in any case of hepatic vein occlusion because the prevalence of this mutation in the general population is high.

Portal and mesenteric vein thrombosis in a patient heterozygous for a mutation (Arg506-->Gln) in the factor V gen (factor V Leiden)

In 30-50% of patients with portal thrombosis, no underlying etiology is found. The recent reports of new hereditary clotting defects are contributing to the understanding of this problem, but they only justify a small number of idiopathic cases. Instead, anticoagulant protein C resistance, caused by a mutation in the V factor gene, appears to be at least 10 times more common than any of the other known inherited deficiencies of anticoagulant proteins. In spite of that, extensive thrombosis of portomesenteric or hepatic venous circulation has been rarely described in this hereditary clotting defect. We report a typical case of familial and recidivant deep vein thrombosis in a young man heterozygous for the factor V Leiden mutation (Arg506-Gln), who developed an acute portal and mesenteric vein thrombosis. The patient was discharged with an oral anticoagulant treatment and remains asymptomatic 2 years later. In conclusion, the high prevalence of the factor V Leiden in young and aged patients with idiopathic vein thrombosis and the case here described makes it obligatory to consider this disorder in patients with portal and/or mesenteric vein thrombosis, especially in those without evident etiology.

Acute Budd-Chiari Syndrome Associated with Activated Protein C Resistance During Intravenous Anticoagulant Treatment

The Budd-Chiari syndrome is a rare but serious condition defined as hepatic venous outflow obstruction. This article presents a case of acute Budd-Chiari syndrome in a 43-year-old woman with activated protein C resistance while she was being treated with intravenous heparin infusion for previously documented deep venous thrombosis. Activated protein C resistance caused by factor V Leiden mutation has emerged as the most prevalent hereditary cause of venous thromboembolism and should be considered as an etiologic factor in patients with Budd-Chiari syndrome.

Budd-Chiari syndrome related to factor V Leiden mutation

We here describe a young patient who presented with chronic Budd-Chiari syndrome. An exhaustive etiological investigation to detect a procoagulable state was negative except for factor V mutation (factor V Leiden), a factor associated with resistance to activated protein C. Factor V Leiden is known to be a common, high risk factor for thrombosis. This factor should be routinely investigated in patients with Budd-Chiari syndrome, as factor V Leiden mutation is probably the procoagulable state responsible for many cases of "idiopathic" Budd-Chiari syndrome.