Milestones in the discovery of Budd-Chiari syndrome

Budd-Chiari syndrome in a patient with antiphospholipid syndrome: hiding in plain sight

We describe the case of a woman in her 40s on lifelong anticoagulation with warfarin due to antiphospholipid syndrome presenting with acute right upper quadrant pain. Liver tests were only slightly elevated, and non-invasive imaging such as Doppler ultrasound and contrast-enhanced CT were non-diagnostic. As suspicion for a thrombotic complication persisted, repeat CT imaging ultimately confirmed the diagnosis of Budd-Chiari syndrome (BCS), and angiography was performed allowing for effective treatment with balloon angioplasty. This case highlights both the need for a high degree of clinical suspicion for BCS in patients with prothrombotic features (even those on anticoagulation) and also the diagnostic and therapeutic potential of interventional radiology in selected cases.

Reversion of liver cirrhosis after endovascular treatment in Chinese patients with Budd-Chiari syndrome

AIMS

To investigate the impact of endovascular (EV) treatment on liver cirrhosis in Chinese patients with Budd-Chiari syndrome (BCS).

METHODS

From September 2011 to March 2022, 97 patients from four hospitals in China who were diagnosed with primary BCS complicated with liver cirrhosis and received EV treatment were retrospectively enrolled in this study for clinical analysis. In addition, liver tissues for basic research were acquired from 25 patients between June 2022 and March 2023, including six with benign liver tumors, 11 with BCS before EV treatment, and eight with EV-treated BCS. Liver cirrhosis was assessed by clinical outcomes, histological studies, and the expression of related genes at the mRNA and protein levels.

RESULTS

The patients with BCS had better liver function after EV treatment, evidenced by an increased albumin level and reduced total bilirubin, ALT, and AST. The imaging findings suggested an amelioration of liver cirrhosis and portal hypertension, including increased portal vein velocity (13.52 ± 8.89 cm/s vs. 17.51 ± 6.67 cm/s, p < 0.001) and decreased liver stiffness (30.37 ± 6.39 kPa vs. 23.70 ± 7.99 kPa, p < 0.001), portal vein diameter (14.97 ± 3.42 mm vs. 13.36 ± 2.89 mm, p < 0.001), and spleen volume (870.00 ± 355.61 cm3 vs. 771.36 ± 277.45 cm3 , p < 0.001). Furthermore, histological studies revealed that EV treatment resulted in a restoration of liver architecture with reduced extracellular matrix deposition. Meanwhile, hepatic angiogenesis and inflammation, which have a close relationship with cirrhosis, were also inhibited. In addition, the state of hepatocytes switches from apoptosis to proliferation after EV treatment.

CONCLUSIONS

BCS-induced liver cirrhosis could be reversed by EV treatment from macroscopic to microscopic dimensions. Our study may provide further insights into understanding BCS and treating cirrhosis.

Extracellular vesicles-transmitted long non-coding RNA MTUS2-5 promotes proliferation and vascularization of human vascular endothelial cells in patients with Budd-Chiari syndrome

The high rates of misdiagnosis and untreated mortality with regard to Budd-Chiari syndrome (BCS) indicated the need to screen effective biomarkers. The aim of this study was to explore the function of extracellular vesicles (EVs) in patients with BCS as well as associated mechanisms. First, differentially expressed long non-coding RNAs (lncRNAs) from EVs separated from serum between BCS and healthy controls were screened using microarray analysis. Second, the proliferation, migration and tube formation of human vascular endothelial cells (HUVECs) were detected after EVs treatment, along with vascular endothelial growth factor (VEGF) levels and inflammatory factors from the cell supernatant. Last, the overexpressed lncRNA was transfected into the cells to further explore the mechanisms involved. Extracellular vesicles of BCS patients have significantly higher levels of lncRNA MTUS2-5 than healthy controls. Apparently, treatment with EVs from BCS or the ones transfected with plasmids that overexpress lncRNA MTUS2-5 enhances proliferation, migration and angiogenesis capacity. The results were considerably better than those obtained from treatment with EVs from healthy controls or transfection with the normal control plasmid, which also elevated the level of VEGF and inflammatory factors. Furthermore, FOS and PTGS2 were potentially regulated by the lncRNA MTUS2-5 transmitted by EVs. The lncRNA MTUS2-5 in EVs plays an important role in angiogenesis in the Budd-Chiari syndrome.

Vascular liver diseases: A sex-oriented analysis of the literature

Vascular liver diseases are an heterogenous group of diseases that collectively represent an important health issue in the field of liver diseases. This narrative review was elaborated by the Special Interest Group (SIG) "Gender in Hepatology" of the Italian Association for the Study of the Liver (AISF). We aimed to review the current knowledge regarding the potential role of biological sex in patients with vascular liver diseases such as splanchnic vein thrombosis, hepatic vein thrombosis, porto-sinusoidal vascular disorder, and hereditary hemorrhagic telangiectasia. As vascular liver diseases commonly affect young individuals, including women in childbearing age, we also included a specific section on the management of pregnancy in these challenging patients.

The role of transjugular intrahepatic portosystemic shunt in patients with cirrhosis and ascites: Recent evolution and open questions

In selected patients with cirrhosis and ascites, transjugular intrahepatic portosystemic shunt (TIPS) placement improves control of ascites and may reduce mortality. In this review, we summarize the current knowledge concerning the use of TIPS for the treatment of ascites in patients with cirrhosis, from pathophysiology of ascites formation to hemodynamic consequences, patient selection, and technical issues of TIPS insertion. The combination of these factors is important to guide clinical decision-making and identify the best strategy for each individual patient. There is still a need to identify the best timing for TIPS placement in the natural history of ascites (recurrent vs. refractory) as well as which type and level of renal dysfunction is acceptable when TIPS is proposed for the treatment of ascites in cirrhosis. Future studies are needed to define the optimal stent diameter according to patient characteristics and individual risk of shunt-related side effects, particularly hepatic encephalopathy and insufficient cardiac response to hemodynamic consequences of TIPS insertion.

Transient Budd–Chiari syndrome secondary to blunt traumatic bile fistula: A case report

Budd–Chiari syndrome (BCS) is rarely caused by trauma. We reported a case of transient and secondary BCS post polytrauma that resulting from massive perihepatic and abdominal fluid and compressed liver, causing stenosis of the inferior vena cava and hepatic veins. This was a special BCS case related to but not directly caused by trauma. With conservative management and active surgical procedures, the patient recovered well.

Budd-Chiari Syndrome during Long-term Follow-up after Allogeneic Umbilical Cord Blood Transplantation

A series of abdominal computed tomography scans of an asymptomatic 40-year-old woman with a history of umbilical cord blood transplantation (CBT) for leukemia at 19 years old revealed the long-term gradual development of a right hepatic vein thrombus and stenosis of the inferior vena cava, leading to a diagnosis of Budd-Chiari syndrome. The Budd-Chiari syndrome in this case might have been influenced by the patient's history of multiple liver abscesses after CBT and associated thrombus formation, in addition to the hormone replacement therapy with estradiol and dydrogesterone she was taking. This case provides insight into the development of Budd-Chiari syndrome.

Misdiagnosis of Budd Chiari syndrome, a case report from Afghanistan

Introduction

Budd-Chiari syndrome is a rare disease characterized by hepatic venous flow obstruction. The obstruction may be thrombotic or non-thrombotic anywhere along the venous course from the hepatic venules to the inferior vena cava (IVC) junction to the right atrium. In clinical practice, cases can be misdiagnosed, particularly in regions where resources are limited, unless the clinician pays special attention to such diagnosis.

Case report and clinical discussion

Here, we would like to present a misdiagnosed case of Budd Chiari syndrome. This reported case is a case of 30 years old female patient complaining of dull abdominal pain and swelling. Initially, the patient consulted a local health facility where the patient was diagnosed with tuberculous peritonitis and subsequently treated with an anti-TB regimen empirically. Within a few days of taking medicine, she developed mild jaundice and lower limb edema. At this stage, the patient came to us, which after taking history, her physical examination unveiled mild jaundice, ascites, abdominal tenderness, and mild lower limb petting edema. The patient was recommended an abdominal CT scan with contrast, which revealed early enhancement and enlargement of the caudate lobe and non-opacification of hepatic veins with narrowing of the hepatic part of the inferior vena cava consistent with Budd-Chiari syndrome. The patient was started on warfarin and referred for a hepatic decongestive procedure. After four months of performing a transjugular portosystemic shunt, the patient came to us for follow-up. She had an excellent clinical improvement and was started on rivaroxaban 20 mg daily orally.

Conclusion

The main takeaway lesson of this particular case is to consider the differential diagnosis of ascites from an etiologic point of view and not to overemphasize a single etiology.

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Budd-Chiari syndrome misdiagnosed with tuberculous peritonitis

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SARS-CoV-2 virus infection must be bear in mind as a possible etiology

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Detailed patient history and an accurate physical examination are crucial to guide us to the exact diagnosis.

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It is necessary to check liver function tests before prescribing any hepatotoxic drug to avoid any future misconception.

Comparison of long-term outcomes of balloon angioplasty with or without stent placement for hepatic vein type Budd-Chiari syndrome

PURPOSE

To compare percutaneous transluminal balloon angioplasty (PTBA) alone with PTBA plus stent placement for Budd-Chiari syndrome (BCS) patients with short-segmental obstruction of hepatic vein.

METHODS

Between May 2001 and December 2010, 91 hepatic vein type BCS patients (mean age, 32.8 ± 10.8; M:F ratio 50:41) were included and divided into two groups (PTBA alone, as group A, n = 48; PTBA plus stent, as group B, n = 43). The incidence of restenosis, long-term patency, and survival were evaluated.

RESULTS

All 91 patients were successfully treated with hepatic vein recanalization. During follow-up period (median 161 months, range: 84-234), group B had a significantly higher proportion of hepatic vein restenosis (56%, 24/43) than group A (33%, 16/48; P < 0.05). Cumulative primary patency rates at 1, 5, 10, 15 years were 96%, 81%, 69%, 65% and 91%, 60%, 47%, 47% in group A and group B, respectively (log-rank P < 0.05). Secondary technical success rates of target hepatic vein were 93% and 57% in group A and group B, respectively (P < 0.05). Clinical complete response rates were 94% and 86% in group A and group B, respectively (P > 0.05). The 15-year cumulative survival rates were 98% and 95% in group A and group B, respectively (P > 0.05). Major procedure-related complications occurred in 3 (3%) patients (1 in group A, 2 in group B).

CONCLUSIONS

Hepatic vein recanalization is safe and efficient for hepatic vein type BCS patients with hepatic vein short segmental obstruction. Restenosis after hepatic vein stenting is more common and difficult to manage than that after hepatic vein balloon angioplasty alone.

Transjugular intrahepatic portosystemic shunts in portal vein thrombosis: A review

The presence of portal vein thrombosis (PVT) has previously been considered a contraindication to the insertion of transjugular intrahepatic portosystemic shunts (TIPSS). However, patients with PVT may have portal hypertension complications and may thus benefit from TIPSS to reduce portal venous pressure. There is an increasing body of literature that discusses the techniques and outcomes of TIPSS in PVT. This review summarizes the techniques, indications and outcomes of TIPSS in PVT in published case reports, case series and comparative trials, especially regarding the reduction in portal hypertensive complications such as variceal bleeding. A comprehensive literature search was conducted using MEDLINE and PubMed databases. Manuscripts published in English between 1 January 1990 and 1 March 2021 were used. Abstracts were screened and data from potentially relevant articles analyzed. TIPSS in PVT has been reported with high levels of technical success, short-term portal vein recanalization and long-term PV patency and TIPSS patency outcomes. Several comparative studies, including randomized controlled trials, have shown favorable outcomes of TIPSS compared with non-TIPSS treatment of PVT complications. Outcomes of TIPSS with PVT appear similar to those in TIPSS without PVT. However, TIPSS may be more technically difficult in the presence of PVT, and such procedures should be performed in expert high-volume centers to mitigate the risk of procedural complications. The presence of PVT should no longer be considered a contraindication to TIPSS. TIPSS for PVT has been acknowledged as a therapeutic strategy in recent international guidelines, although further studies are needed before recommendations can be strengthened. KEY POINTS: Portal vein thrombosis (PVT) is no longer a contraindication to the insertion of transjugular intrahepatic portosystemic shunts (TIPSS) TIPSS often leads to the spontaneous dissolution of PVT, but can be combined with mechanical or pharmacological thrombectomy TIPSS reduces portal hypertensive complications of PVT, such as variceal bleeding, and can also facilitate liver transplantation where PVT may otherwise interfere with vascular anastomoses Studies have shown favorable long-term outcomes of TIPSS compared with TIPSS without PVT; as well as compared with non-TIPSS treatment of PVT complications TIPSS in PVT should be performed in high-volume specialist centers due to technical difficulties.

Chronic Drug-Induced Liver Injury: Updates and Future Challenges

Chronic drug-induced liver injury (DILI), defined as DILI with persistent liver injury more than one year after the first onset by the latest European guidelines, is a notable challenge globally with big issues of defining causality and establishing effective treatment. About 20% of patients with DILI develop into chronic DILI. Chronic DILI manifests as persistent or repeated inflammatory or diminishing bile ducts, even progresses to cirrhosis and needs liver transplantation eventually. However, research on chronic DILI over the last decades is still lacking, and the incidence, phenotypes, mechanisms, risk factors, and treatment have not been fully understood. In this paper, we reviewed the definition of chronic DILI, updated clinical studies in terms of incidence, special manifestations, and promising risk factors of chronic DILI, along with the recent progress and challenges in glucocorticoid therapy.

Management of portal hypertension severe complications

Portal hypertension is a clinical syndrome characterized by an increase in the portal pressure gradient, defined as the gradient between the portal vein at the site downstream of the site of obstruction and the inferior vena cava. The most frequent cause of portal hypertension is cirrhosis. In patients with cirrhosis, portal hypertension is the main driver of cirrhosis progression and development of hepatic decompensation (ascites, variceal hemorrhage and hepatic encephalopathy), which defines the transition from compensated to decompensated stage. In decompensated patients, treatments aim at lowering the risk of death by preventing further decompensation and/or development of acute-on-chronic liver failure. Decompensated patients often pose a complex challenge which typically requires a multidisciplinary approach. The aims of the present review were to discuss the current knowledge regarding interventional treatments for patients with portal hypertension complications as well as to highlight useful information to aid hepatologists in their clinical practice. Specifically, we discussed the indications and contraindications of transjugular intra-hepatic portosystemic shunt and for the treatment of gastro-esophageal variceal hemorrhage in patients with decompensated cirrhosis (first section); we reviewed the use of interventional treatments in patients with hepatic vein obstruction (Budd-Chiari Syndrome) and in those with portal vein thrombosis (second section); and we briefly comment on the most frequent applications of selective splenic embolization in patients with and without underlying cirrhosis (third section).

A study of the different parameters in acute and chronic Budd–Chiari syndrome

Background

Budd–Chiari syndrome (BCS) is a rare and potentially life-threatening vascular disease of the liver. There are a few studies on the differences between acute and chronic BCS in clinical and laboratory characteristics, as well as the outcomes, so we designed this research to study the different parameters in acute and chronic BCS. Diagnosis of BCS was made using Doppler ultrasound, magnetic resonance imaging, and venography. Patients with BCS were then divided into chronic and acute groups based on both imaging characteristics and disease duration. Finally, the outcomes, clinical features, and laboratory parameters of acute and chronic BCS were compared.

Results

In total, 60 patients were included in this study, of whom 28.3% and 71.7% had acute and chronic BCS, respectively. According to clinical features, spontaneous bacterial peritonitis (PR 1.289; 95% CI 1.115–1.489; P = 0.001) and jaundice (PR 1.308; 95% CI 1.148–1.490; P < 0.001) were significantly associated with chronic than acute BCS. According to laboratory parameters, the levels of international normalized ratio (INR) (PR 0.953; 95% CI 0.918–0.989; P = 0.012), blood urea nitrogen (BUN) (PR 0.996; 95% CI 0.993–1.000; P = 0.039), and model for end-stage liver disease (MELD) score (PR 1.024; 95% CI 1.012–1.037; P < 0.001) in chronic group were significantly higher than in the acute BCS. The hospital length of stay (LOS) and mortality rate between the two groups did not differ significantly.

Conclusions

This study showed that the spontaneous bacterial peritonitis, jaundice, increased levels of MELD score, INR, and BUN were significantly associated with the chronic group compared with the acute group. The hospital LOS and mortality rate between the two groups did not differ significantly. Further research is recommended to clarify this issue.

Budd-Chiari Syndrome: An Uncommon Cause of Chronic Liver Disease that Cannot Be Missed

Budd-Chiari syndrome (BCS), or hepatic venous outflow obstruction, is a rare cause of liver disease that should not be missed. Variable clinical presentation among patients with BCS necessitates a high index of suspicion to avoid missing this life-threatening diagnosis. BCS is characterized as primary or secondary, depending on etiology of venous obstruction. Most patients with primary BCS have several contributing risk factors leading to a prothrombotic state. A multidisciplinary stepwise approach is integral in treating BCS. Lifelong anticoagulation is recommended. Long-term monitoring of patients for development of cirrhosis, complications of portal hypertension, hepatocellular carcinoma, and progression of underlying diseases is important.