Ultrasound and MR findings in acute Budd-Chiari syndrome with histopathologic correlation

[Budd-Chiari syndrome, review and illustration]

Budd-Chiari syndrome is a rare vascular disorder characterized by obstruction of the hepatic venous outflow. Various diseases causing coagulopathy play a role in aetiology, such as myeloproliferative disorders. Acute vascular occlusion may lead to acute phlebitis with fever. The classic triad of acute liver failure may be present with ascites, hepatomegaly, and abdominal pain. However, subacute courses of disease were also observed. Because of the variable symptoms and severity extent, depending on the acuity of the course and the extent of the affected vessels, diagnosis is often difficult. Sonography, as a ubiquitously available and cost-effective diagnostic tool, plays a leading role. Doppler ultrasonography can be used to visualize hemodynamics in particular. In acute thrombotic occlusion, the affected hepatic veins usually cannot or only partially be visualized. In non-occluding thrombi, turbulent flow patterns may develop in the area of venous outflow obstruction, and flow velocity is then increased in the area of stenosis. Contrast enhanced ultrasound offers even better specificity of diagnosis. Computed tomography and magnetic resonance imaging can directly visualize thrombi and the cause of obstruction. Once the diagnosis is confirmed, anticoagulation must be initiated, but therapy of the underlying disease must also be started. If symptom-controlling measures are not sufficient, angioplasty/stenting to reopen short-segment stenoses or implantation of a TIPSS device may be considered. Liver transplantation remains ultima ratio. As studies on the precision of diagnostic methods are controversial, the characteristics of imaging for BCS are therefore summarized in this review on the basis of several illustrating case reports.

Comparative study of MRI manifestations of acute and chronic Budd-Chiari syndrome

BACKGROUND

Magnetic resonance imaging (MRI) is able to diagnose Budd-Chiari syndrome (BCS) by distinguishing differential imaging features of acute and chronic forms of the disease. However, the characteristic imaging differences are still not clear as previous data were mostly obtained from scattered small samples instead of large comparative study.

AIM

To investigate MRI manifestations of acute and chronic (BCS), and to evaluate the value of MRI for diagnosis of acute and chronic BCS.

METHODS AND RESULTS

We retrospectively compared MRI results of 24 patients with acute and 82 patients with chronic BCS using Mann-Whitney U test for ascites volume, and Fisher's exact test for intrahepatic venous collaterals and extra-hepatic venous collaterals. In the acute group, MRI findings suggested thrombosis in hepatic vein (HV) in all acute patients and additional inferior vena cava (IVC) thrombosis in 5 patients. In the chronic BCS group, 6 and 15 patients showed solitary obstruction either in the IVC or HV, respectively, while 61 patients showed combined IVC and HV obstruction. More patients with acute BCS presented with ascites accompanied with high signals on T2WI from intravenous obstructive lesions. Further, the average maximal spleen diameter in patients with acute BCS, and the ratio of patients with acute BCS developing intrahepatic venous collaterals and extra-hepatic venous collaterals were also lower compared with chronic BCS. All these differences were statistically significant.

CONCLUSION

MRI indicates direct and indirect features of BCS, and therefore enables accurate diagnosis of acute and chronic BCS.

Diagnosis and management of Budd Chiari syndrome: an update

Imaging plays a crucial role in the early detection and assessment of the extent of disease in Budd Chiari syndrome (BCS). Early diagnosis and intervention to mitigate hepatic congestion is vital to restoring hepatic function and alleviating portal hypertension. Interventional radiology serves a key role in the management of these patients. The interventionist should be knowledgeable of the clinical presentation as well as key imaging findings, which often dictate the approach to treatment. This article concisely reviews the etiology, pathophysiology, and clinical presentation of BCS and provides a detailed description of imaging and treatment options, particularly interventional management.

Diagnostic and interventional radiology for Budd-Chiari syndrome

Budd-Chiari syndrome is a heterogeneous group of disorders characterized by hepatic venous outflow obstruction that involves one or more draining hepatic veins. Its occurrence in populations in the western hemisphere is commonly associated with hypercoagulative states. Clinical manifestations in many cases are nonspecific, and imaging may be critical for early diagnosis of venous obstruction and accurate assessment of the extent of disease. If Budd-Chiari syndrome is not treated promptly and appropriately, the outcome may be dismal. Comprehensive imaging evaluations, in combination with pathologic analyses and clinical testing, are essential for determining the severity of disease, stratifying risk, selecting the appropriate therapy, and objectively assessing the response. The main goal of treatment is to alleviate hepatic congestion, thereby improving hepatocyte function and allowing resolution of portal hypertension. Various medical, endovascular, and surgical treatment options are available. Percutaneous and endovascular procedures, when performed in properly selected patients, may be more effective than medical treatment methods for preserving liver function and arresting disease progression in the long term. In addition, such procedures are associated with lower morbidity and mortality than are open surgical techniques.

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.

Hepatobiliary imaging and its pitfalls

In summary, US is the initial imaging modality for the evaluation of acute right upper quadrant pain. It permits accurate diagnosis of acute cholecystitis and successfully identifies multiple other causes of patient symptomatology. Some of these processes lie outside the hepatobiliary system and include renal infection and obstruction, pancreatitis and its sequelae, duodenal or colonic perforation or mass lesions, peritoneal tumor spread, adrenal hemorrhage, and even remote problems, such as pneumonia. The limitations on US include incomplete imaging of the liver, most often at the dome or beneath ribs on the surface, and incomplete visualization of lesion boundaries, particularly with some infections and tumors. For these clinical scenarios, contrast-enhanced CT is complementary to US and should be encouraged. In the biliary tree, US has limitations in situations in which the ducts are not dilated and sometimes with imaging the extra hepaticducts, especially distally. For these patients, CT or MR imaging (MRCP) is especially useful. If one keeps the clinical scenario in mind and always images a patient where he or she hurts, US is a powerful and effective diagnostic method for evaluating acute right upper quadrant pain.

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Magnetic resonance imaging of diffuse liver diseases

The intrinsic soft tissue contrast and exquisite sensitivity to contrast agents are unique attributes of magnetic resonance imaging that are beneficial when evaluating diffuse liver disease. Much like a pathologist uses different tissue or cell marker stains, the magnetic resonance imager can use a variety of imaging strategies to elucidate pathologic liver processes in vivo, including processes leading to abnormal lipid metabolization, iron deposition, perfusion abnormalities related to inflammation, fibrosis, vascular occlusion, or infarction and hemorrhage. This article reviews the most important diffuse liver diseases and the corresponding magnetic resonance imaging features.

Contrast agents for MR imaging of the liver

A variety of different categories of contrast agents, and within each category a number of individual agents, are currently available for clinical use in magnetic resonance (MR) imaging of the liver. In this review, the use of nonspecific extracellular gadolinium chelates, reticuloendothelial system-specific iron oxide particulate agents, hepatocyte-selective agents, and combined perfusion and hepatocyte-selective agents are described. Most clinical experience is with nonspecific extracellular gadolinium chelates. The relatively low cost, safety, good patient tolerance, and ability to help detect and characterize a wide range of liver diseases have rendered gadolinium chelates as commonly used agents. Reticuloendothelial system-specific agents improve lesion detection by decreasing the signal intensity of background liver on T2-weighted MR images, which increases the conspicuity of focal hepatic lesions with negligible reticuloendothelial cells (eg, metastases). Hepatocyte-selective agents increase the signal intensity of background liver on T1-weighted images, which increases the conspicuity of focal lesions that do not contain hepatocytes (eg, metastases). The clinical application of the different categories of contrast agents, techniques for their administration, sequences to be used, and appearances of common entities on contrast agent-enhanced studies are described.

Budd-Chiari syndrome: spectrum of appearances of acute, subacute, and chronic disease with magnetic resonance imaging

The purpose of this study was to describe our collective experience in the magnetic resonance (MR) investigation of patients with proven acute, subacute, and chronic Budd-Chiari syndrome and to demonstrate the spectrum of appearances on T1- and T2-weighted as well as dynamic post-gadolinium spoiled gradient-echo imaging. All patients with proven Budd-Chiari syndrome who underwent MR examinations between June, 1992 and October, 1998 were included in the study. Fourteen patients were included in the study: four with acute, three with subacute, three with chronic, and four with acute superimposed on either subacute (two) or chronic (two) Budd-Chiari syndrome. MR imaging features were retrospectively evaluated to determine: a) liver morphology, b) pattern of signal intensity (SI) on T1-weighted images, c) pattern of SI on T2 weighted images, d) dynamic enhancement characteristics, e) presence or absence of visible venous thrombosis, and f) presence or absence of venous macroscopic collaterals. The MR findings were correlated with surgical, histopathological, and laboratory data to determine imaging characteristics related to the chronicity of the disease process. Hepatic venous thrombosis or absence of hepatic venous flow was demonstrated in all patients in the study. In the four patients with acute Budd-Chiari syndrome, the liver periphery was moderately low signal on T1 and moderately high signal on T2-weighted images relative to the central liver; both early and late gadolinium-enhanced images revealed diminished peripheral enhancement. In the three patients with subacute Budd-Chiari syndrome, the liver periphery was moderately low signal on T1, and moderately high signal on T2-weighted images, while early and late gadolinium-enhanced images revealed heterogenously increased enhancement within the liver periphery. In the three patients with chronic Budd-Chiari syndrome, the SI differences between peripheral and central liver were minimal on T1- and T2-weighted images, and enhancement differences were also minimal. Extensive bridging intrahepatic and capsular venous collaterals were visualized in chronic cases. In the four patients with acute Budd-Chiari syndrome superimposed on more chronic disease, a combination of gadolinium enhancement patterns was observed on MR images. Enhancement patterns between central and peripheral liver were different for acute, subacute, and chronic Budd-Chiari syndromes, suggesting differentiation between these phases of the disease process. Application of this pattern approach permitted recognition of acute changes superimposed on more chronic disease.

Budd-Chiari Syndrome

Many options are available to diagnose and treat patients with the Budd-Chiari syndrome who present with either thrombotic or non-thrombotic occlusion of the major hepatic veins and or vena cava. The goal of therapy is to alleviate venous obstruction and to preserve hepatic function. Low-sodium diets, diuretics, and therapeutic paracentesis are generally ineffective, except for the rare patient who presents with volume overload and incomplete hepatic venous occlusion. Anticoagulants and thrombolytics may be appropriate for selected patients with acute thrombotic venous obstruction. Percutaneous transluminal angioplasty (PTA) of hepatic venous stenoses or caval webs with or without placement of intraluminal stents yield excellent short-term results, but additional studies are warranted to assess long-term efficacy. Transjugular intrahepatic portosystemic shunts (TIPS) may be effective for patients with subacute or chronic disease and ascites refractory to sodium restriction and diuretics. Intrahepatic stents may also serve as a bridge to transplantation for selected patients presenting with fulminant hepatic failure consequent to hepatic venous occlusion. Additional studies will be necessary to assess the role of TIPS in the armamentarium of therapies for patients with the Budd-Chiari syndrome. Decompressive shunts, reconstruction of the vena cava and hepatic venous ostia, transatrial membranotomy, and dorsocranial resection of the liver with hepatoatrial anastomosis are appropriate options for patients with acute or subacute disease who are not candidates for, or fail less invasive therapies. The majority of patients benefit with improvement in liver function tests, ascites, and liver histology; however, hepatic function may deteriorate in patients with marginal reserve. Liver transplantation is reserved for patients with Budd-Chiari syndrome who present with fulminant hepatic failure or end-stage liver disease with portal hypertensive complications. Transplantation is also appropriate for patients who deteriorate after failed attempts at surgical shunting.

Budd-Chiari syndrome: a short radiological review

A short review of Budd-Chiari syndrome (BCS) is given with detailed radiological findings from ultrasound, computed tomography (CT) and angiography and illustrated with two case reports. The cases had different clinical presentations: one antedated by Behçet's syndrome and complicated with aortic aneurysm, the other with a provisional diagnosis of a tuberculous abdomen. The radiological features of BCS, especially the changing appearance under dual-phase CT, are discussed. The respective diagnostic sensitivity and efficacy of other imaging modalities are mentioned.