Budd-Chiari syndrome in a premature infant receiving total parenteral nutrition

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.

Budd-Chiari disease in infancy: three cases

Budd-Chiari syndrome (BCS) is rare in infancy. Three cases are presented. Case 1, an 8-month-old boy, presented with abdominal distension and oliguria. Doppler study of the abdomen showed ascites, hepatomegaly and normal hepatic veins. However, a CT scan demonstrated hepatic vein thrombosis. Case 2, a 5-month-old boy, presented with abdominal distension and diarrhoea. Ultrasound of the abdomen showed hepatic vein thrombosis and hepatomegaly. Case 3, a 7-month-old girl, presented with abdominal distension, diarrhoea and oliguria. Ultrasound of the abdomen showed hepatomegaly and obstructed hepatic veins. None of the cases had fever or jaundice before presentation. Case 1 developed fungal septicaemia and was lost to follow-up. Cases 2 and 3 succumbed to the disease before further intervention.

Budd-Chiari syndrome: A case with a combination of hepatic vein and superior vena cava occlusion

We here report a recent, rare case of Budd-Chiari syndrome, associated with a combination of hepatic vein and superior vena cava occlusion. A young female, who had been in good health, was admitted to our hospital because of massive ascites. The patient had used no oral contraceptives. Tests for coagulation disorders, hematological disorders, and antiphospholipid syndrome were all negative. Budd-Chiari syndrome was diagnosed by radiographic examination. The patient was suffering from a combination of hepatic vein and superior vena cava occlusion. In particular, the venous flow returned from the liver mainly through a right accessory hepatic vein, and stenosis was recognized at the orifice of this collateral vein into the vena cava. Subsequently, the patient underwent percutaneous balloon dilatation therapy for this stenosis. After this treatment, the massive ascites was gradually reduced, and she was discharged from our hospital. It has now been one year since discharge, and the patient has been doing well. If deteriorating liver function or intractable ascites occur again, a liver transplantation may be anticipated. This is the first case report of Budd-Chiari syndrome associated with a superior vena cava occlusion.

Unusual hepatic-portal-systemic shunting demonstrated by Doppler sonography in children with congenital hepatic vein ostial occlusion

PURPOSE

This report describes unusual changes in the hepatic vasculature in 3 children presenting with upper gastrointestinal hemorrhage.

METHODS

The study included 3 children (ages 5-8 years) who presented with hematemesis. All had mild hepatosplenomegaly and normal liver function. Esophageal varices were demonstrated in all on upper endoscopy. Color and spectral Doppler sonography was performed to assess the hepatic vasculature, including the hepatic veins (HVs), portal vein (PV), hepatic artery (HA), and inferior vena cava (IVC).

RESULTS

The HVs were all patent but with ostial occlusion at the point of their communication with the IVC. Complete flow reversal was shown inside the HVs, with blood draining into collateral vessels at the liver surface and paraumbilical vein. In one patient, the paraumbilical vein could be traced to its communication with the right external iliac vein. In all children, the direction of flow in the PV, HA, and IVC was normal. After endoscopic sclerotherapy, all children were shown to be in good general condition and to have normal liver function for a follow-up period of 15-36 months.

CONCLUSIONS

Ostial occlusion of the HV is a rare cause of hepatic outflow obstruction in children. Doppler sonography is a valuable, noninvasive imaging technique for evaluation of the hepatic vasculature and the accompanying shunting pathways in such cases.

Management of a small bowel transplant with complicated central venous access in a patient with asymptomatic superior and inferior vena cava obstruction

During the past few years, small bowel transplantation (SBT) has become a realistic alternative for patients with irreversible intestinal failure who have or will develop severe complications from total parenteral nutrition (TPN). Transplantation can be associated with large fluid shifts and massive blood loss necessitating rapid infusions of large quantities of crystalloid and/or blood products. Invasive monitoring and large-bore venous access are necessary in order to manage these patients intraoperatively. Because patients with irreversible intestinal failure are often managed with total parenteral nutrition via a central venous catheter, thrombotic intraluminal obstruction of major vessels may develop over time. Additionally, this may lead to superior vena cava (SVC) syndrome as well as challenging problems with vascular access. We present a 34-year-old woman with a past medical history for long-standing Crohn's disease with multiple small bowel resections and short gut syndrome who presented for an SBT. The patient had a long history of TPN use, complicated by SVC syndrome and inferior vena cava (IVC) obstruction. She was presently asymptomatic from her SVC obstruction. Central venous access was obtained by an interventional radiologist. A 7-French double-lumen Hickman minicatheter was placed in the left femoral vein with the tip of the catheter positioned just distal to the IVC narrowing. A left radial 20-gauge arterial line was placed for hemodynamic monitoring and frequent blood sampling. The patient's left and right dorsal-saphenous veins were cannulated with 16-guage catheters and adequate flow was observed. Lower extremity pressure was measured via the Hickman catheter in the left femoral vein. A multiplane transesophageal echo was used to assess ventricular volume. The options and intraoperative management of such patients are discussed.

Calcified thrombus in the right atrium: a rare complication of long-term parenteral nutrition in a child

A 5-year-old boy with short-bowel syndrome who receives home parenteral nutrition developed a calcified thrombus that involved the inferior vena cava (IVC) and the right atrium. Symptoms included 3 to 4 months of intermittent fever and 2 months of vague chest pain. Blood could not be aspirated from the IVC catheter and an IVC contrast study demonstrated the calcified thrombus. The intracardiac portion of the mass was removed surgically, but the IVC mass could not be completely excised. The boy developed a pericardial effusion 6 weeks after surgery. He was treated for this and 6 months after the initial surgery the patient was asymptomatic.

Thrombogenicity of total parenteral nutrition solutions: I. Effect on induction of monocyte/macrophage procoagulant activity

Although thrombosis is a frequent complication of total parenteral nutrition (TPN), its pathogenesis has received little scientific attention. We have studied, in vitro, the effects of the component solutions of TPN on the induction and modulation of human monocyte procoagulant activity, an initiator of coagulation. Human peripheral blood mononuclear cells were cultured with (a) 200 microliters of dextrose solution (10%, 15%, 20%, 25%, and 50%), (b) 200 microliters of amino acid solution (full, one-half, and one-quarter strength), and (c) 200 microliters of isosmolar 10% lipid emulsion (LE). Cocultures of LE and 20% dextrose, LE and full-strength amino acid solution, and LE and bacterial lipopolysaccharide were also studied. Cells cultured with lipopolysaccharide or medium alone constituted positive and negative controls, respectively. In addition, cocultures of LE and 20% dextrose, LE and full-strength amino acid solution, and LE and lipopolysaccharide were also studied. Cells were incubated for intervals of 12-72 h, washed, frozen, and assayed for monocyte procoagulant activity (MPCA). Milliunits of MPCA were derived from a standard thromboplastin curve. In addition, spontaneous MPCA levels were measured in healthy volunteers (n = 4) and "home" total parenteral nutrition patients (n = 4) before and after a 2-h infusion of 500 ml of LE. Our results show that, in vitro, hypertonic dextrose and full-strength amino acid solutions induce significant levels of MPCA. Induction of MPCA by dextrose was lymphocyte-independent. Although a significant increase in MPCA by full-strength amino acid solution was seen in cultures of isolated monocytes, a lymphocyte requirement was demonstrated for full MPCA. In contrast, LE significantly inhibited the induction of MPCA by 20% dextrose and full-strength amino acid solution. This inhibitory activity was at the monocyte level. Subfractionation of the LE into triglyceride and phospholipid phases showed the inhibitory capacity to reside in the former. In vivo, patients on home total parenteral nutrition expressed higher spontaneous MPCA levels than normal controls. Ten percent lipid emulsion infusion abolished MPCA expression in both groups. These corroborative in vitro and in vivo data suggest a mechanism for the thrombogenicity of total parenteral nutrition solutions and that the inhibitory properties of LE may be of practical advantage in preventing thrombosis.

Budd-Chiari syndrome in children: report of 22 cases

Clinical, radiologic, and histologic features in 22 children with Budd-Chiari syndrome are reported. Three children had acute refractory ascites; all the others had hepatomegaly, which was detected either fortuitously or because of abdominal pain or distention. Results of liver function tests were normal or only moderately abnormal. In most cases a combination of ultrasonography and needle liver biopsy pointed to the diagnosis of Budd-Chiari syndrome, which was confirmed by angiography. Eighteen children underwent surgery involving various techniques, depending on the degree of patency of the inferior vena cava. Five children died postoperatively. Histologic studies of the liver, carried out in 12 of the surviving children, showed disappearance or regression of centrilobular hemorrhagic infiltration. Half of the surviving surgical patients are now free of complications after a follow-up of 7 months to 7 years; the others have either secondary thrombosis of the inferior vena cava or stenosis of the shunt or have experienced late pulmonary complications. Our results suggest that (1) Budd-Chiari syndrome must be considered a possible diagnosis in children with firm hepatomegaly and normal or near normal liver function, (2) surgery provides good results in many instances, and (3) the possibility of late complications requires careful follow-up.