Diagnosis and Therapy of Visceral Vein Thrombosis: An Update Based on the Revised AWMF S2k Guideline

Splanchnic or visceral vein thromboses (VVTs) are atypical thrombotic entities and include thrombosis of the portal vein, hepatic veins (Budd-Chiari syndrome), mesenteric veins, and splenic vein. All VVTs have in common high 30-day mortality up to 20% and it seems to be difficult to diagnose VVT early because of their rarity and their wide spectrum of unspecific symptoms. VVTs are often associated with myeloproliferative neoplasia, thrombophilia, and liver cirrhosis. VVT is primarily diagnosed by sonography and/or computed tomography. In contrast to venous thromboembolism, D-dimer testing is neither established nor helpful. Anticoagulation is the first-line therapy in patients with stable circulation and no evidence of organ complications. Anticoagulation improves significantly recanalization rates and stops the progress of thrombosis. Low-molecular-weight heparin, vitamin K antagonists, as well as direct-acting oral anticoagulants are possible anticoagulants, but it is noteworthy to be aware that all recommendations supporting the off-label use of anticoagulants are based on poor evidence and consist predominantly of case series, observational studies, or studies with small case numbers. When choosing a suitable anticoagulation, the individual risk of bleeding and thrombosis must be weighted very carefully. In cases of bleeding, bowel infarction, or other complications, the optimal therapy should be determined on a case-by-case basis by an experienced multidisciplinary team involving a surgeon. Besides anticoagulation, there are therapeutic options including thrombectomy, balloon angioplasty, stenting, transjugular placement of an intrahepatic portosystemic shunt, liver transplantation, and ischemic bowel resection. This article gives an overview of current diagnostic and therapeutic strategies.

Primary Budd-Chiari syndrome versus sinusoidal obstruction syndrome: a review

Budd-Chiari syndrome (BCS) and sinusoidal obstruction syndrome (SOS) are two major vascular disorders of the liver, of which both can cause portal hypertension related complications, but their locations of obstruction are different. BCS refers to the obstruction from the hepatic vein to the junction between the inferior vena cava and right atrium, which is the major etiology of post-sinusoidal portal hypertension; by comparison, SOS is characterized as the obstruction at the level of hepatic sinusoids and terminal venulae, which is a cause of sinusoidal portal hypertension. Both of them can cause hepatic congestion with life-threatening complications, especially acute liver failure and chronic portal hypertension, and share some similar features in terms of imaging and clinical presentations, but they have heterogeneous risk factors, management strategy, and prognosis. Herein, this paper reviews the current evidence and then summarizes the difference between primary BCS and SOS in terms of risk factors, clinical features, diagnosis, and treatment.

[Budd-Chiari syndrome with hepatopulmonary syndrome: a case report and literature review]

Objective: To summarize the clinical features and prognosis of Budd-Chiari syndrome with hepatopulmonary syndrome (HPS) in children. Methods: The clinical data of a child who had Budd-Chiari syndrome with HPS treated at the Department of Pediatrics of the First Affiliated Hospital of Zhengzhou University in December 2016 was analyzed retrospectively. Taking "Budd-Chiari syndrome" and "hepatopulmonary syndrome" in Chinese or English as the keywords, literature was searched at CNKI, Wanfang, China Biomedical Literature Database and PubMed up to July 2023. Combined with this case, the clinical characteristics, diagnosis, treatment and prognosis of Budd-Chiari syndrome with HPS in children under the age of 18 were summarized. Results: A 13-year-old boy, presented with cyanosis and chest tightness after activities for 6 months, and yellow staining of the skin for 1 week. Physical examination at admission not only found mild yellow staining of the skin and sclera, but also found cyanosis of the lips, periocular skin, and extremities. Laboratory examination showed abnormal liver function with total bilirubin 53 μmol/L, direct bilirubin 14 μmol/L, and indirect bilirubin 39 μmol/L, and abnormal blood gas analysis with the partial pressure of oxygen of 54 mmHg (1 mmHg=0.133 kPa), the partial pressure of carbon dioxide of 31 mmHg, and the alveolar-arterial oxygen gradient of 57 mmHg. Hepatic vein-type Budd-Chiari syndrome, cirrhosis, and portal hypertension were indicated by abdominal CT venography. Contrast-enhanced transthoracic echocardiography (CE-TTE) was positive. After symptomatic and supportive treatment, this patient was discharged and received oxygen therapy outside the hospital. At follow-up until March 2023, there was no significant improvement in hypoxemia, accompanied by limited daily activities. Based on the literature, there were 3 reports in English while none in Chinese, 3 cases were reported. Among a total of 4 children, the chief complaints were dyspnea, cyanosis, or hypoxemia in 3 cases, and unknown in 1 case. There were 2 cases diagnosed with Budd-Chiari syndrome with HPS at the same time due to respiratory symptoms, and 2 cases developed HPS 1.5 years and 8.0 years after the diagnosis of Budd-Chiari syndrome respectively. CE-TTE was positive in 2 cases and pulmonary perfusion imaging was positive in 2 cases. Liver transplantation was performed in 2 cases and their respiratory function recovered well; 1 case received oxygen therapy, with no improvement in hypoxemia; 1 case was waiting for liver transplantation. Conclusions: The onset of Budd-Chiari syndrome with HPS is insidious. The most common clinical manifestations are dyspnea and cyanosis. It can reduce misdiagnosis to confirm intrapulmonary vascular dilatations with CE-TTE at an early stage. Liver transplantation is helpful in improving the prognosis.

[Splanchnic vein thrombosis]

Splanchnic vein thrombosis includes Budd-Chiari syndrome and portal vein thrombosis. These diseases share common features: (i) they are rare diseases and (ii) they can lead to portal hypertension and its complications. Budd-Chiari syndrome and portal vein thrombosis in the absence of underlying liver disease share many risk factors, the most common being myeloproliferative neoplasms. A rapid and comprehensive workup for thrombosis risk factors is necessary in these patients. Long-term anticoagulation is indicated in most patients. Portal vein thrombosis can also develop in patients with cirrhosis, and is associated with a worse course of cirrhosis. Indications for anticoagulation in patients with cirrhosis are increasing. Transjugular intrahepatic portosystemic shunt is a second-line procedure in this setting. Because of the rarity of these diseases, high-level evidence studies are rare. However, collaborative studies have provided a better understanding of their natural history and allowed to improve the management of these patients. This review focuses on the causes, diagnosis, and management of patients with Budd-Chiari syndrome, patients with portal vein thrombosis without underlying liver disease, and patients with cirrhosis and portal vein thrombosis.

Significance of histopathological features in the diagnosis of Budd-Chiari syndrome on liver biopsies

Background

Budd-Chiari syndrome (BCS) requires a constellation of clinical, imaging, and histological findings for diagnosis. Liver biopsy serves as a tool for confirming the diagnosis, even though the histological characteristics are not pathognomonic.

Aims

To determine which constellation of morphologic findings could aid in establishing a diagnosis of BCS in clinically suspected cases.

Materials and Methods

A 5-year retrospective observational study was conducted. The clinical, laboratory, and histological findings of liver biopsies in patients with a clinical diagnosis of BCS were studied. Cases were segregated into two groups on the basis of the number of histological features present. A scoring system was then devised to assess the efficacy of the histological findings in diagnosing BCS.

Statistical Analysis Used

The continuous variables were compared using the Mann-Whitney U-test, and categorical variables were compared using the Fisher-exact test.

Results

The common histopathological findings were the presence of red blood cells in the space of disse (100%), peri-portal fibrosis (97.1%), sinusoidal dilation (97.1%), portal inflammation (67.6%), centrilobular necrosis (61.8%) and pericellular/sinusoidal fibrosis (61.8%). Comparison between the two groups showed that centrilobular necrosis, lobular inflammation, portal inflammation, central vein fibrosis, and pericellular/sinusoidal fibrosis were significant parameters. No correlation was found between the clinical and laboratory parameters and the two groups.

Conclusions

The liver biopsy features in BCS are often nonspecific, and no single feature in isolation is characteristic. A constellation of features (centrilobular necrosis, lobular inflammation, portal inflammation, central vein fibrosis, and pericellular/sinusoidal fibrosis), when present together, indicate the possibility of BCS.

Budd-Chiari Syndrome-A Single Center Experience From the United Kingdom

Pediatric Budd-Chiari syndrome (BCS) is a rare cause of portal hypertension and liver disease in Europe and North America. In order to understand the long-term effect of radiological intervention on BCS we performed a single center retrospective review. Fourteen cases were identified; 6 of 14 (43%) had a congenital thrombophilia with many having multiple prothrombotic mutations. Two were managed with medical anticoagulation alone and two required super-urgent transplant for acute liver failure. The remaining 10 of 14 (71%) underwent radiological intervention: 1 of 14 thrombolysis, 5 of 14 angioplasty, and 4 of 14 transjugular intrahepatic portosystemic shunt (TIPS). Six of 14 (43%) patients required repeat radiological intervention (1 angioplasty, 5 TIPS) but none required surgical shunts or liver transplantation for chronic liver disease. The time between diagnosis and treatment did not predict the need for repeat radiological intervention. These data show that radiological intervention can be highly effective, and reduces the need for surgery, though it requires specialist multidisciplinary teams for monitoring.

Buddi-Chiari syndrome associated with hypereosinophilic syndrome: A case report

RATIONALE

Budd-Chiari Syndrome (BCS) is a relatively rare clinical disorder with a wide range of symptoms, caused by the obstruction of the hepatic venous outflow. The etiology and pathogenesis of BCS vary in different countries and regions. In Western countries, hepatic venous obstruction is the most common type, and its main cause is closely related to the hypercoagulable state of the body. Inferior vena cava obstruction is common in Asia, and its etiology progresses slowly due to the lack of epidemiological data. [3] Here, we report a rare case of BCS associated with the hypereosinophilic syndrome and discuss the possible causal relationship between the two.

PATIENT CONCERNS

The patient was a 33-year-old female with intermittent epistaxis, gum bleeding, and excessive menstrual flow for the past 6 months. The routine blood tests showed elevated levels of eosinophils, and the liver function test showed mildly elevated levels of γ-glutamyl transpeptidase and alkaline phosphatase, and abdominal ultrasound showed hepatosplenomegaly and suspicion of intrahepatic arteriovenous or arteriovenous-portal fistula.

DIAGNOSES

Finally, through the improvement of bone marrow aspiration, digital subtraction angiography and gene detection, the diagnosis of BCS combined with hypereosinophilic syndrome was confirmed, and JAK2V617F mutation was highly associated with it.

INTERVENTIONS

The patient received endovascular stent implantation and regular oral rivaroxaban anticoagulation therapy after operation.

OUTCOMES

Seven months later, enhanced computed tomography (CT) of the hepatobiliary showed that the hepatic bruise-like changes were significantly reduced compared with before, and the right hepatic vein and the right perihepatic vein stent were left in place with a good filling of contrast in the stent.

LESSONS

The patient, in this case, was finally diagnosed with BCS combined with hypereosinophilic syndrome, and to our knowledge, such case reports are rare. Our case report suggest an association between BCS and hypereosinophilic syndrome, but relevant studies are minimal, we hope to conduct larger and higher quality studies on these patients in the future, to provide new directions and basis for the etiology and pathogenesis of these diseases, as well as provide new targets and ideas for clinical treatment.

A remarkable presentation of a massive Budd-Chiari syndrome

A 59-year-old female presented to the emergency department with malaise, significant weight loss, abdominal discomfort, dyspnoea and severely swollen peripheral extremities. She had a past medical history of sickle cell anaemia, a latent tuberculosis infection and a chronic hepatitis B that was treated with PEG-interferon alpha-2 in 2008. Since 2018, she was lost to follow-up. The patient was critically ill, sarcopenic and lethargic. Clinical examination revealed icteric sclerae and a markedly distended and diffusely tender abdomen and peripheral oedemas. Her vital signs included a blood pressure of 105/64 mmHg, tachycardia of 130 bpm, hypothermia of 35.6°C and a SpO2 of 100% in ambient air. Laboratory workup demonstrated a total bilirubin of 12.9 mg/dL, AST 500 U/L, ALT 218 U/L, ALP 178 U/L and GGT 126 U/L, a thrombocytopenia of 34 x10E3/ μL, 16,01 x10E3/μL leukocytes, a CRP of 94.8 mg/L and a lactate of 10,12 mmol/L. The serum creatinine was 1.04 mg/dL, eGFR 54.1 ml/min. The INR was 2.77 and there was a severe hypoalbuminemia (22 g/L). D-dimers were >20 000 ng/ml. The patient presented also with spontaneous hypoglycaemia. A multiphasic contrast-enhanced thoracic and abdominal computed tomography (CT) was performed (figure 1). Given the results of the CT, a 2D echocardiogram was urgently requested (figure 2).

How to treat patients with splanchnic vein thrombosis: recent advances

Splanchnic vein thrombosis (SVT) is an unusual-site venous thromboembolism that includes portal, mesenteric, and splenic vein thrombosis as well as the Budd-Chiari syndrome. SVT is a relatively rare disease (portal vein thrombosis and Budd-Chiari syndrome are, respectively, the most and the least common presentations); roughly one‑third of the cases are detected incidentally, and liver cirrhosis and solid cancer represent the main risk factors. Once SVT is diagnosed, careful patient evaluation should be performed to assess the stage, grade, and extension of the thrombosis, as well as the risks and benefits of the anticoagulation regimen. Anticoagulant therapy is effective in SVT treatment and is associated with high rates of vein recanalization, low rates of thrombosis progression or recurrence, and an acceptable rate of bleeding complications. Most available data come from observational studies in patients with liver cirrhosis-related SVT receiving low‑molecular‑weight heparin or vitamin K antagonists. Data on the use of direct oral anticoagulants are increasing and promising. In selected patients and in specialized centers, interventional procedures may be considered in adjunction to anticoagulation in the cases of mesenteric or extensive SVT, intestinal ischemia, or in the patients whose condition deteriorates despite adequate anticoagulant therapy. In this narrative review, we summarize the available data regarding anticoagulation in patients with SVT, identify specific subgroups of patients who may achieve the greatest benefits from anticoagulant therapy, and provide practical advice for clinicians caring for these patients.

Budd-Chiari syndrome (BCS): a challenging diagnosis not to be overlooked-single center report and pictorial essay

Budd-Chiari syndrome (BCS) is a rare disease with a variable clinical presentation and often late diagnosis. Doppler ultrasonography (DUS) permits to determine the site of the obstructed venous tracts, the thrombotic or non-thrombotic nature of the obstruction with its morphologic features and the flow-pattern alterations. Other non-specific findings, which are seen in most of the other liver diseases, include ascites, hepatosplenomegaly and caudate hypertrophy. The aim of this study is to show our experience in BCS reporting retrospectively 15 cases referred to our hepatology center between 2017 and 2021. Four selected cases depict the extreme heterogeneous behaviour of BCS and highlight the importance of DUS as a diagnostic tool when there is a clinical suspicion. In patients, mainly young, who present with ascites and abdominal pain, BCS has to be considered and DUS is the first imaging technique to be performed to rule it out.

[SOLVING A MEDICAL MYSTERY THROUGH THE EYES OF A YOUNG PATIENT WITH BUDD-CHIARI SYNDROME AND A NEW VISION LOSS]

INTRODUCTION

Budd-Chiari syndrome is a heterogeneous group of disorders characterized by venous drainage obstruction of the liver and is extremely rare. The clinical manifestations are usually ascites, varicose veins and in severe cases - hepatic insufficiency. Behcet's disease is a chronic, idiopathic, inflammatory disease that manifests as obstructive vasculitis and affects a variety of organ systems. Ocular involvement occurs in approximately 70% of the patients, and is a major clinical criterion in the diagnosis. Rarely, Behcet's disease can be a cause of Budd-Chiari syndrome. In these cases, the diagnosis has a crucial impact on the treatment and prognosis of the patients since patients with Budd-Chiari syndrome secondary to Behcet's disease, will usually improve under systemic medications with no need for surgery. In addition, in these patients there is a higher chance for developing hepatocellular carcinoma so they need to have a tight and a long follow-up.

DISCUSSION

In this article we discuss a case of a young patient with Budd-Chiari syndrome, who was examined due to acute vision loss in his left eye. Left eye examination revealed panuveitis presenting with anterior uveitis, intermediate uveitis and an occlusive retinal vasculitis. The ocular examination raised suspicion that the diagnosis was Behcet's disease. Actually, Budd-Chiari syndrome was part of the presentation of Behcet's disease, which was not diagnosed until he was examined by us. The patient was treated with corticosteroid therapy and biological treatment with adalimumab, an anti-TNF drug. During follow-up, a complete resolution of the intraocular inflammation was achieved, as well as stabilization of its general condition, with the disappearance of the clinical signs indicative of liver failure.

Budd-Chiari Syndrome and Hepatic Vascular Diseases Professional Committee of Chinese Research Hospital Association. [Chinese multidisciplinary collaborative expert consensus for the diagnosis and treatment of Budd-Chiari syndrome (2021 version)]

Budd-Chiari syndrome (B-CS) is a complicated hepatic vascular disease caused by hepatic venous outflow obstruction.There are significant differences in the pathogenesis and treatment of B-CS between China and Western countries.Given the characteristics of B-CS in our country,Budd-Chiari Syndrome and Hepatic Vascular Diseases Professional Committee of Chinese Research Hospital Association organizes domestic experts in this field to formulate the "Chinese multidisciplinary collaborative expert consensus for the diagnosis and treatment of Budd-Chiari syndrome（2021 version）".This consensus elaborates the research status of epidemiology,pathogenesis,disease classification,clinical manifestations,diagnosis and treatment of B-CS in China.Conducting basic research on pathogenesis and clinical research with high level evidence are important work direction in the future.This consensus is expected to provide guidance for clinicians to make optimal therapeutic schedules,so as to further standardize and improve the comprehensive diagnosis and treatment and basic research level of B-CS in China.

From Budd-Chiari syndrome to acquired von Willebrand syndrome: thrombosis and bleeding complications in the myeloproliferative neoplasms

Thrombotic and hemorrhagic complications are prevalent in patients with essential thrombocythemia, polycythemia vera, and myelofibrosis. Given the impact on morbidity and mortality, reducing the risk of thrombosis and/or hemorrhage is a major therapeutic goal. Historically, patients have been risk stratified on the basis of traditional factors, such as advanced age and thrombosis history. However, multiple factors contribute to the thrombotic tendency, including gender, mutational profile, inflammatory stress, and abnormal cell adhesion. Management includes cardiovascular risk reduction and use of antiplatelet therapy, depending on myeloproliferative neoplasm subtype and mutational status. Anticoagulation is a mainstay of therapy for those with venous thrombosis, but practice patterns remain heterogeneous. Cytoreduction is indicated for higher-risk patients, but efficacy may depend on the involved vascular bed. Management of special situations, such as unusual site thrombosis, bleeding, the perioperative period, and pregnancy, are especially challenging. In this article, risk factors and treatment strategies for myeloproliferative neoplasm thrombosis and bleeding, including special situations, are reviewed. Insights gained from recent studies may lead to the development of a more precise risk classification and tailored therapy.

Type II Abernethy Malformation in a Patient with Primary Budd-Chiari Syndrome

Budd-Chiari syndrome (BCS) is a heterogeneous group of disorders characterized by hepatic venous outflow obstruction. Abernethy malformation is a congenital vascular malformation defined by diversion of portal blood away from the liver. Both conditions are rare vascular diseases. We report here the first case of a patient with combined type II Abernethy malformation and BCS from China. The inferior vena cava obstruction was treated with percutaneous balloon angioplasty; close follow-up was elected for the Abernethy malformation.

Splanchnic vein closures

Closures in the splanchnic venous system (SVS) represent a broad medical problem. Anatomically, individual or even multiple sections of SVS may be affected at the same time. Main sections of SVS include the venous liver outflow system, the portal vein, and the upper mesenteric vein and its basin. Thrombosis is clearly the predominant cause of closure. The closures can present as acute, subacute, chronic occult or chronic manifest. The main pathological and anatomical units are the Budd-Chiari syndrome (BCS), extrahepatic portal vein obstruction (EHPVO) and mesenteric vein thrombosis (MVT). Advanced laboratory, imaging and intervention methods substantially modify the approach to prevention, diagnosis and treatment; surgical approach also plays a role. The problem of SVS closures is interdisciplinary.

[Splanchnic vein thrombosis]

Splanchnic vein thromboses include thrombosis of the portal venous system (including the portal, mesenteric and splenic vein) and hepatic vein thrombosis (also called Budd-Chiari syndrome). They are rare manifestations of venous thromboembolism. These thromboses are frequently associated with local or systemic factors. The therapeutic approach is often complex due to heterogeneity of patients and limited available data in the literature. The cornerstone of treatment is anticoagulation. However, the bleeding risk, related to portal hypertension, should be accurately assessed to individualize the treatment. A multidisciplinary consultation team including several specialists is provided at the University Hospitals of Geneva for the optimal management of those patients.

Liver cirrhosis caused by chronic Budd-Chiari syndrome

Chronic Budd-Chiari syndrome (BCS) is a rare cause of liver cirrhosis (LC) and tends to be misdiagnosed in clinical practice. In order to characterize LC caused by chronic BCS, we conducted this retrospective observational study. Medical records of all patients who were initially diagnosed as chronic BCS with LC when discharged from our department from January, 2011 to October, 2016 were reviewed. Cirrhotic patients with known causes and cases lacked key data were excluded. Data of remaining patients was collected and analyzed. A total of 15 cases were included in this study. Patients with LC caused by chronic BCS were characterized by preserved liver function and prominent portal hypertension (PH). Abdominal distention and edema of lower extremities were most common initial manifestations. Intra- or extrahepatic collaterals on imaging studies were of great importance for differential diagnosis. Most of these patients received interventional angioplasty followed by anticoagulation with warfarin and survived without obvious complications of PH. Chronic BCS was a rare but important cause of LC and should always be considered in patients with chronic liver disease and so-called cryptogenic LC. Early diagnosis and timely treatment may improve outcome. Correct interpretation of imaging examinations was fundamental to avoiding misdiagnosis.

Clinical Characteristics and Outcome of Budd-Chiari Syndrome at a Tertiary Care Hospital in Pakistan

OBJECTIVE

To determine the clinical characteristics of Budd-Chiari syndrome (BCS), its causes and outcome at a tertiary care hospital.

STUDY DESIGN

An observational study.

PLACE AND DURATION OF STUDY

The Aga Khan University Hospital,Karachi, from 2004 to 2014.

METHODOLOGY

Aretrospective analysis of data was conducted. Apredesigned questionnaire was filled from medical records of patients with BCS. Clinical features, etiology, management and outcome was noted from 2004 to 2014. Descriptive statistics were determined.

RESULTS

Forty-five patients' charts were reviewed; 26 (57.8%) were male patients. The median (IQR) age at diagnosis was 26.0 (20.5 to 34.5) years. Primary BCS was seen in 27 (60.0%) patients. The most frequent clinical features included ascites (82.2%), abdominal pain (55.6%), and hepatomegaly (31.1%). Acombined hepatic vein/inferior vena cava block was found in 25 (55.6%) patients. Out of the 28 tested patients protein C and protein S deficiencies were detected in 22 (78.6%) and 17 (60.7%) patients, respectively. Antithrombin III deficiency was detected in 14 (58.3%) of those tested patients. Anticoagulants were used in 24 (53.3%) patients. TIPS was done in 11 (24.4%) patients. Mortality was 6.7% (n=3).

CONCLUSION

Congenital thrombophilia was a major causal factor. Age, clinical features, biochemistry and management are important factors in survival.

Validation of prognostic indices in Egyptian Budd-Chiari syndrome patients: A single-center study

AIM

To compare predictive ability of Budd-Chiari syndrome (BCS) prognostic indices (PIs) for one-year survival and Transjugular intrahepatic portosystemic shunt (TIPS) patency.

METHODS

This retrospective study enrolled 194 Egyptian patients with primary BCS who presented to the Budd-Chiari Study Group of Ain Shams University Hospital. Calculation of the available PIs was performed using Child-Pugh and model for end-stage liver disease scores, BCS-specific PIs (Clichy, New Clichy and Rotterdam) for all patients, and BCS-TIPS PI only for patients who underwent TIPS. The overall one-year survival rate and the one-year shunt patency rate for TIPS were reported.

RESULTS

The overall one-year survival rate was 69.6%, and the New Clichy PI revealed the best validity for its prediction at a cut-off value of 3.75, with sensitivity and specificity of 78% and 73.3%, respectively [area under receiver operating characteristic curve (AUC) = 0.806]. The one-year survival rate post-TIPS was 89.7%, and the BCS-TIPS score demonstrated validity for its prediction at a cut-off value of 3.92 (sensitivity and specificity were 71.4% and 64.5%, respectively) (AUC = 0.715). Logistic regression analysis revealed that the New Clichy PI (P = 0.030), high serum total bilirubin (P = 0.047) and low albumin (P < 0.001) were independent factors for predicting mortality within one year. The one-year shunt patency rate in TIPS was 80.2%, and none of the PIs exhibited significant validity for its prediction.

CONCLUSION

The New Clichy score could independently predict the one-year survival in Egyptian BCS patients.

Liver Transplantation for Budd-Chiari Syndrome With Large Solitary Focal Nodular Hyperplasia of the Liver in a Patient With Essential Thrombocythemia: Case Report. [Corrected]

Budd-Chiari syndrome is a rare condition caused by interrupted hepatic venous outflow in the hepatic veins, inferior vena cava, or right atrium. Reports from the literature have delineated on focal nodular hyperplasia (FNH)-like lesions in association with Budd-Chiari Syndrome. To our knowledge, there are no reports about true FNH lesions in patients with Budd-Chiari Syndrome. Focal nodular hyperplasia develops in disorders with aberrant circulation and vasculature. We report a case of Budd-Chiari syndrome in association with large solitary FNH in a 22-year-old man who was referred to our institution with sudden intermittent right upper quadrant abdominal pain, vomiting, diarrhea with pale stool, decreased appetite, dark urine, and abdominal distention for 15 days. Laboratory investigations revealed anemia, thrombocytosis, and abnormal liver function tests and coagulation profile. Imaging revealed hepatic vein thrombosis, confirming Budd-Chiari syndrome, and a 6.2 × 6.1 × 6.8 cm lesion in segment 8 of the liver. Primary cause of Budd-Chiari syndrome was essential thrombocythemia according to bone marrow biopsy and molecular testing results. The patient was treated medically and underwent transjugular intrahepatic portosystemic shunt insertion. The lesion in segment 8 continued to enlarge. Cadaveric liver transplantation was carried out. On gross and histologic examination of the explanted liver, the lesion was found to be a true FNH.

Diagnosis, etiology and management of the Budd-Chiari Syndrome: a bloodcoagulation and hepatological study on the course of the disease treated with TIPS

BACKGROUND

Budd-Chiari Syndrome (BCS) is characterized by obstruction of blood flow in hepatic veins. The aim of the study was to analyze diagnosis, etiology and management of BCS.

METHODS

We analyzed 44 patients (32 females, 12 males, the mean age <35y of age) treated with TIPS. Ascites was found in 35 patients as the most frequent symptom. The median of total follow-up was 52 months. Non-covered (bare) or covered stent was inserted to all patients. Diagnosis of myeloproliferative neoplasm (MPN) was based on WHO criteria. Other inherited or acquired thrombophilia were assessed as well. Therapy of BCS was with regard to the etiology.

RESULTS

The etiology of BCS was identified in 38 cases. Ph- MPN was found as the most common risk factor (50%, N.=22), especially polycythemia vera. JAK2V617F mutation was detected in the most of 22 MPN cases (82.5%). The second most common etiologic factor was inherited thrombophilia (18%, N.=8). In the non-covered (bare) stent group, a primary patency rates 52.9% in 1 year and 20% in 5 years after TIPS (Portasystemic Shunt, Transjugular Intrahepatic) creation. In the covered stent group the 1-year and 5-year primary patency rates were was 80% and 33.3% respectively. The average 5-year re-intervention rate per patient was 1.65 procedures in the bare stent group and 0.67 in the covered stent group. Re-interventions were more frequent in MPN patients. All patients were anticoagulated with heparin at the beginning, switched to vitamin K antagonist. On top of TIPS, anticoagulant and a vigorous therapy of underlying disorder are necessary.

CONCLUSION

BCS is a serious and life-threatening disorder in MPD is a major cause of morbidity and mortality. Therapy requires a multidisciplinary approach. Insertion of TIPS dedicated covered stent is a very effective treatment in cases resistant to conservative approach with lower dysfunction rate and the number of re-interventions.

Budd-Chiari Syndrome in a patient with Multiple Hypercoagulopathies

OBJECTIVE

To describe a patient with Budd-Chiari syndrome (BCS) found to have multiple hypercoagulopathies.

CASE SUMMARY

A 33-year-old man who presented with abdominal distension, hematemesis, shortness of breath was found to have liver cirrhosis, portal hypertension and Budd-Chiari Syndrome. He was evaluated for hypercoagulability and was found to be heterozygous for Factor V Leiden mutation and his protein C level was 38% of normal. He was started on oral anticoagulation and underwent elective liver transplantation within 3 months of diagnosis.

DISCUSSION

In patients with Budd-Chiari syndrome, factor V Leiden is the second most commonly identified prothrombotic state after primary myeloproliferative disorders. There may be a coexistence of several thrombophilic states in patients with Budd-Chiari Syndrome.

CONCLUSIONS

Budd-Chiari syndrome is an uncommon disorder. Outcome is poor in many cases. Therefore, a successful diagnostic and therapeutic approach is of vital importance. A complete thrombophilia screening needs to be requested in all patients diagnosed with Budd-Chiari syndrome. Thorough investigation needs to be performed to identify an underlying process contributing to the hepatic venous outflow obstruction.

[Budd-Chiari syndrome: a case report and review of the literature]

We report the history of a 20-year-old woman admitted for thrombosis of the sus-hepatic veins and of the inferior vena cava (IVC) with extension of the thrombus into the right atrium. The etiological research was negative and a diagnosis of idiopathic Budd-Chiari syndrome was retained. In view of the absence of vein repermeabilisation under adequate anticoagulant therapy, a venous thrombectomiy was performed under cardiopulmonary bypass, which improved the hepatic venous drainage. Budd-Chiari syndrome is a very serious disorder. Its treatment implies a step by step procedure. An effective anticoagulation must first be established. The complications of portal hypertension then require attention. For a symptomatic patient, one should assess the possibility of restoring the venous permeability, improving the hepatic drainage and decompressing the liver by radiological interventional or surgical procedures. Finally, an hepatic transplantation should be considered in case of treatment ineffectiveness, of fulminant hepatic failure, or of an evolution towards cirrhosis.

Retrograde puncture assisted hepatic vein recanalization in treating Budd-Chiari syndrome with segmental obstruction of hepatic vein

PURPOSE

This study aimed at investigating the feasibility and effectiveness of retrograde puncture assisted hepatic vein (HV) recanalization in management of Budd-Chiari syndrome (BCS) patients with segmental obstruction of HV.

MATERIALS AND METHODS

From May 2011 to August 2014, 76 BCS patients with obstruction of HV were treated by routine transjugular HV recanalization in our center. Among them, 17 patients with segmental obstruction (obstruction length >1 cm) of HV experienced failure of the routine transjugular HV recanalization and underwent retrograde puncture assisted HV recanalization. Data on technical success, clinical success and follow-up were collected and analyzed retrospectively.

RESULTS

Retrograde puncture assisted HV recanalization was technically successful in 14 of 17 (82 %) patients. Of these 14 patients, 12 patients underwent HV balloon dilation, and 2 patients underwent HV stent insertion. No procedure-related complications occurred in any of our patient. Clinical success was achieved in all of the 14 patients who experienced technical success. The mean HV pressure decreased from 43.6 ± 6.7 cmH2O before treatment to 18.4 ± 4.8 cmH2O after treatment (P < 0.001). BCS-related symptoms began to improve on the next day following the treatment. During 4-43 months (mean 17.4 ± 10.8 months) of follow-up, three patients experienced re-obstruction of HV.

CONCLUSIONS

Retrograde puncture assisted HV recanalization is a simple, safe, and effective treatment for BCS patients with segmental obstruction of HV. It can serve as an additional treatment option for patients who experience the technical failure of routine transjugular HV recanalization.

Survival and prognostic indicators of Budd-Chiari syndrome: a systematic review of 79 studies

This paper aimed to systematically review the survival of Budd-Chiari syndrome and to identify the most robust prognostic predictors. Overall, 79 studies were included. According to the treatment modalities, the median 1-, 5- and 10-year survival rate was 93, 83 and 73% after interventional radiological treatment; 81, 75 and 72.5% after surgery other than liver transplantation; 82.5, 70.2 and 66.5% after liver transplantation and 68.1, 44.4% and unavailable after medical therapy alone. According to the publication years, the median 1-, 5- and 10-year survival rate was 68.6, 44.4% and unavailable before 1990; 75.1, 69.5 and 57% during the year 1991-1995; 77, 69.6 and 65.6% during the year 1996-2000; 86.5, 74 and 63.5% during the year 2001-2005 and 90, 82.5 and 72% after 2006. Bilirubin, creatinine and ascites were more frequently identified as significant prognostic factors in univariate analyses. But their statistical significance was less frequently achieved in multivariate analyses.

Portal vein aneurysm associated with Budd-Chiari syndrome treated with transjugular intrahepatic portosystemic shunt: A case report

A 65-year-old woman with Budd-Chiari syndrome (BCS) presented with right upper quadrant pain. A computed tomography (CT) scan showed a saccular aneurysm located at the extrahepatic portal vein main branch measuring 3.2 cm in height and 2.5 cm × 2.4 cm in diameter. The aneurysm was thought to be associated with BCS as there was no preceding history of trauma and it had not been present on Doppler ultrasound examination performed 3 years previously. Because of increasing pain and concern for complications due to aneurysm size, the decision was made to relieve the hepatic venous outflow obstruction. Transjugular intrahepatic portosystemic shunt (TIPS) was created without complications. She had complete resolution of her abdominal pain within 2 d and remained asymptomatic after 1 year of follow-up. CT scans obtained after TIPS showed that the aneurysm had decreased in size to 2.4 cm in height and 2.0 cm × 1.9 cm in diameter at 3 mo, and had further decreased to 1.9 cm in height and 1.6 cm × 1.5 cm in diameter at 1 year.

Transjugular intrahepatic portosystemic shunt for severe jaundice in patients with acute Budd-Chiari syndrome

AIM: To evaluate the feasibility of transjugular intrahepatic portosystemic shunt (TIPS) for severe jaundice secondary to acute Budd-Chiari syndrome (BCS).

METHODS: From February 2009 to March 2013, 37 patients with severe jaundice secondary to acute BCS were treated. Sixteen patients without hepatic venule, hepatic veins (HV) obstruction underwent percutaneous angioplasty of the inferior vena cava (IVC) and/or HVs. Twenty-one patients with HV occlusion underwent TIPS. Serum bilirubin, liver function, demographic data and operative data of the two groups of patients were analyzed.

RESULTS: Twenty-one patients underwent TIPS and the technical success rate was 100%, with no technical complications. Sixteen patients underwent recanalization of the IVC and/or HVs and the technical success rate was 100%. The mean procedure time for TIPS was 84.0 ± 12.11 min and angioplasty was 44.11 ± 5.12 min (P < 0.01). The mean portosystemic pressure in the TIPS group decreased significantly from 40.50 ± 4.32 to 16.05 ± 3.50 mmHg (P < 0.01). The mean portosystemic pressure gradient decreased significantly from 33.60 ± 2.62 to 7.30 ± 2.21 mmHg (P < 0.01). At 8 wk after the procedures, in the TIPS group, total bilirubin (TBIL) decreased significantly from 266.24 ± 122.03 before surgery to 40.11 ± 3.52 μmol/L (P < 0.01) and direct bilirubin (DBIL) decreased significantly from 194.22 ± 69.82 μmol/L to 29.82 ± 3.10 μmol/L (P < 0.01). In the angioplasty group, bilirubin returned to the normal range, with TBIL decreased significantly from 258.22 ± 72.71 μmol/L to 13.33 ± 3.54 μmol/L (P < 0.01) and DBIL from 175.08 ± 39.27 to 4.03 ± 1.74 μmol/L (P < 0.01). Liver function improved faster than TBIL. After 2 wk, in the TIPS group, alanine aminotransferase (ALT) decreased significantly from 50.33 ± 40.61 U/L to 28.67 ± 7.02 U/L (P < 0.01) and aspartate aminotransferase (AST) from 49.46 ± 34.33 U/L to 26.89 ± 8.68 U/L (P < 0.01). In the angioplasty group, ALT decreased significantly from 51.56 ± 27.90 to 14.22 ± 2.59 μmol/L (P < 0.01) and AST from 60.66 ± 39.89 μmol/L to 8.18 ± 1.89 μmol/L (P < 0.01). After mean follow-up of 12.6 mo, there was no recurrence of jaundice in either group.

CONCLUSION: Severe jaundice is not a contraindication for TIPS in patients with acute BCS and TIPS is appropriate for severe jaundice due to BCS.

Clinical presentation and predictors of survival in patients with Budd Chiari syndrome: experience from a tertiary care hospital in Pakistan

OBJECTIVE

To determine aetiology, clinical presentation and predictors of survival in Budd Chiari Syndrome patients.

METHODS

The prospective observational study based on non-probability convenient sampling was conducted at the Sindh Institute of Urology and Transplantation (SIUT), Karachi, and comprised Budd Chiari Syndrome patients between January 2004 and December 2013. The patients were evaluated for onset of symptoms, causes, mode of presentation and predictors of survival. SPSS 20 was used for statistical analysis.

RESULTS

Of the 25 patients, 16(64%) were males, and 16(64%) belonged to the paediatric age group. Overall age range was 2-50 years with a mean of 14.7 ± 12.41 years. Presentation was chronic in 14(56%) patients, acute in 10(40%) and acute on chronic in 1(4%). Commonest morphological abnormality involved was hepatic veins alone in 14(56%). Probable aetiologies were hypercoagulable states in 21(84%) patients, infections in 2(8%) and malignancy in 1(4%). Among hypercoagulable states, protein C deficiency was the commonest, affecting 9 (36%) patients. Seven (28%) patients died; acute 4 (16%) and chronic 3 (12%). Causes of death included sepsis 4 (16%), fulminant hepatic failure 1 (4%), gastrointestinal bleeding 1 (4%), and bleeding from liver biopsy site 1 (4%). Poor survival was associated with bilirubin > 5 mg/dl (p < 0.031), serum alanine transaminase > 40 U/L (p < 0.005), serum albumin < 2.8 g/dl (p < 0.008), Child-Turcotte-Pugh score > 10 (p < 0.001) and absence of varices (p < 0.025). Cox regression analysis failed to show any significant independent predictors of survival.

CONCLUSION

Budd Chiari Syndrome affected young patients more frequently and was associated with high mortality. The commonest aetiology was hypercoagulable state. Survival was poor in patients with decompensated liver disease and those with an acute clinical presentation.

Magnetic resonance venography in the diagnosis of inferior vena cava obstruction in Budd-Chiari syndrome

OBJECTIVE

To evaluate the informativeness of magnetic resonance venography (MRV) in the diagnosis of different types of inferior vena cava (IVC) obstruction.

PATIENTS AND METHODS

56 patients with IVC obstruction underwent MRV scans. These scans were evaluated for morphology of the obstruction and compared with digital subtraction angiography (DSA) images.

RESULTS

Using DSA, we determined that 47 patients had complete obstruction and 9 had partial obstruction. MRV scans revealed 6 cases of partial obstruction. Using MRV, we determined the morphology of the proximal and distal ends of the complete obstructions in the IVC. We classified our observations into cone, plateau, and irregular subtypes. Both DSA and MRV scans were compared to assess the consistency between two methods. MRV demonstrated high sensitivity (100%) for diagnosing a complete obstruction of the IVC, and its specificity was 66.7%. The positive and negative predictive values of MRV were 94% and 100%, respectively.

CONCLUSIONS

MRV imaging is a valuable alternative to DSA for detection of obstructions in the IVC in Budd-Chiari syndrome, particularly in the distal end, which could expedite the decision making for interventional treatment programmes. However, MRV imaging is less suitable for observing the morphology of the proximal ends of obstructions due to the limitations of the scanning plane and the influence of pseudo shadows.

[Liver resection in patient with hcc and right atrium thrombosis]

Presented herein is a case report concerning tumorous thrombosis of the inferior vena cava and right atrium, which is rather an uncommon but severe complication of primary hepatic cancer. The purpose of the article is to demonstrate successful surgical management of locally disseminated hepatic carcinoma complicated by tumorous thrombosis of the inferior vena cava and portal vein, as well as thrombosis of the right atrium. The patient was subjected to dextral hemihepatectomy with thrombectomy from the right portal vein, resection of the right cupola of the diaphragm, marginal resection of the lower lobe of the right lung, thrombectomy from the inferior vena cava and right atrium. The outcome of our case report, as well as literature data suggest that in case of resectability of hepatic tumour complicated by thrombosis of major vessels and even the heart, surgical intervention is justified if there is a possibility to completely remove thrombotic masses along with the primary tumour.

[POSSIBILITIES OF ENDOVASCULAR INTERVENTIONS IN TREATMENT OF BUDD-CHIARI SYNDROME]

The article presents the results of endovascular treatment of 35 patients with Budd-Chiari syndrome. An analysis of efficacy of modern interventions was made. There were shown the. possibilities of balloon dilatation of stenosis of renal veins, the balloon dilatation and stenting with metal self-expansible stents of stenosis an occlusion of intrahepatic section of the postcava and results of transhepatic portsystemic bypass surgery.

Budd-Chiari syndrome: A single-center experience

AIM: To investigate challenges, risk factors, prognostic indicators, and treatment outcomes associated with Budd-Chiari syndrome (BCS) at a tertiary care center.

METHODS: A retrospective cohort study was conducted at the University of Pennsylvania in patients with a diagnosis of BCS or hepatic vein thrombosis. All patients receiving care at the University of Pennsylvania, and who had at least 2 clinical encounters in the University of Pennsylvania Health system from January 1, 2008 to September 10, 2013 were eligible for study inclusion. Data were extracted from the electronic medical record of each patient, and recorded in a secure Research Electronic Data Capture database. Logistic regression analyses were applied to identify predictors of outcome of liver transplant (LT) or death.

RESULTS: Between January 1, 2008 and September 10, 2013, forty-seven patients were identified. Median age was 42.4 years. Thirty-one (66.0%) were women. A majority were Caucasian (68.1%). At diagnosis, 43 (91.5%) patients had ascites, 27 (57.4%) patients had a hematologic disorder associated with a hypercoagulable state and 26 (55.3%) had cirrhosis. Forty (85.1%) patients were on anticoagulation (AC), 30 (63.8%) of whom were maintained on warfarin. Two patients (4.3%) underwent thrombolytic therapy. A transjugular intrahepatic portosystemic shunt (TIPS) was placed in 21 (44.7%) patients, 19 (90.5%) of whom were also on AC. Twenty-one (44.7%) received AC alone. Over a median of 974 d, 8 (17.0%) patients received LT, and 10 (21.3%) died. The median time from listing to death was 26 mo [interquartile range (IQR) = 16, 65)]. TIPS with AC was utilized more frequently in younger patients (P = 0.02). Age, cirrhosis and chronic kidney disease (CKD) were significant predictors of LT or death.

CONCLUSION: AC alone was employed as frequently as TIPS with AC, though the latter was used more frequently in younger patients with polycythemia vera. There were no significant differences in treatment outcome regardless of the therapeutic intervention employed. Significant predictors of poor prognosis included age, cirrhosis and CKD.

Percutaneous endovascular creation of an inferior vena cava in a patient with caval agenesis, Budd-Chiari syndrome, and iliofemorocaval thrombosis

A 29-year-old woman with acute iliofemorocaval thrombosis was discovered to have suprarenal caval agenesis with azygous continuation, hepatic congestion, and fibrosis as a result of chronic Budd-Chiari syndrome. Three staged procedures were performed: pharmacomechanical thrombolysis of acute thromboses, transfemoral liver biopsy and hemodynamic assessment, and percutaneous endovascular creation of a "neocava" lined with endografts. Symptomatic improvement and patency were maintained at 12-week follow-up.

Selection of treatment modalities for Budd-Chiari Syndrome in China: A preliminary survey of published literature

AIM: To evaluate the frequency of use of various treatment modalities for Budd-Chiari syndrome (BCS) in China by conducting a preliminary survey of relevant literature.

METHODS: All papers regarding the treatment of BCS in Chinese patients were identified by searching PubMed, Chinese Scientific and Technological Journal, and China National Knowledge Infrastructure databases. Data regarding the number of BCS patients treated with different treatment modalities over time were collected. The proportions of BCS patients undergoing various treatment modalities were calculated.

RESULTS: Overall, 300 of 3005 papers initially retrieved were included. These papers included 23352 BCS patients treated with different treatment modalities. The treatment modalities include surgery (n = 8625), interventional treatment (n = 13940), surgery combined with interventional treatment (n = 363), medical therapy (n = 277), other treatments (n = 91), and no treatment (n = 56). After 2005, the number of BCS patients treated with surgery was drastically decreased, but the number of BCS patients who underwent interventional treatment was almost maintained. Shunt surgery was the most common type of surgery (n = 3610). Liver transplantation was rarely employed (n = 2). Balloon angioplasty with or without stenting was the most common type of interventional treatment (n = 13747). Transjugular intrahepatic portosystemic shunt was rarely employed (n = 81).

CONCLUSION: Selection of treatment modalities for BCS might be different between China and Western countries. Further work should be necessary to establish a unanimous therapeutic strategy for BCS in China.

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.

The Budd Chiari syndrome: a 22 year male treated successfully with mesocaval shunt

Budd Chiari syndrome (BCS) is a heterogeneous group of disorders characterized by hepatic venous outflow obstruction at any level from the small hepatic veins to the atrio cava junction. BCS could have serious consequences if not treated promptly. Comprehensive angiographic studies, computerised tomography, liver ultrasonography, histology and pathologic analyses are essential for establishing the disease severity, stratifying risk factors, choosing the appropriate therapy and objectively assessing the response. The main objective of therapy is to alleviate portal and IVC hypertension. Here we present a report of a young man with BCS who underwent mesocaval shunt. The eight months follow up showed that patient was free of symptoms and duplex scans confirmed the patency of the shunt.

Scientific publications on portal vein thrombosis and Budd-Chiari syndrome: a global survey of the literature

BACKGROUND & AIMS

Portal vein thrombosis (PVT) and Budd-Chiari syndrome (BCS) are two rare vascular disorders of the liver that can lead to life-threatening complications. We conducted a global survey to systematically analyze the scientific publications in the fields of PVT and BCS.

METHODS

All papers regarding PVT and BCS were identified via the PubMed, EMBASE, and Cochrane library databases. The publication year, country, type of paper, study design, and number of citations were summarized. Good quality papers were defined as those in which a high proportion of homogeneous patients with BCS and/or PVT was observed.

RESULTS

We identified 6691 and 4325 papers regarding PVT and BCS, respectively. The number of papers gradually increased over time. Researchers from the USA published the greatest number of papers (PVT: n=1418; BCS: n=888). Clinical studies were the most common type of paper (PVT: n=5395; BCS n=3171), but fewer than half of these observed more than 10 patients (PVT: n=2667/5395; BCS: n=1092/3171). Furthermore, fewer than half of the clinical studies with more than 10 patients were of good quality (PVT: 976/2667; BCS: 466/1092). According to the study design, the good quality papers were classified as cohort studies (PVT: n=865; BCS: n=421), case-control studies (PVT: n=98; BCS: n=45), and randomized controlled trials (PVT: n=13; BCS: n=0). The 5 most frequently cited original articles and guidelines/consensuses were also listed.

CONCLUSIONS

Despite an increase in the number of papers regarding PVT and BCS over time, most of the papers had a small sample size, suggesting the necessity of large cohort studies or randomized controlled trials.

Management of Budd-Chiari: a single-center experience of 280 cases

OBJECTIVE

Budd-Chiari syndrome (BCS) is a rare and life-threatening disorder secondary to hepatic venous outflow obstruction. How to manage this complex disease has haunted many surgeons. The aim of this study is to investigate the treatment of Budd-Chiari syndrome in our hospital.

METHODS

The clinical data of 280 BCS patients were analyzed retrospectively in our hospital between July 2000 and March 2013.

RESULTS

The total effective rate was 90% (252/280). The rate of mortality was 7.14% (20/280), the rate of complication was 17.14% (48/280). We carried out followup in 198 cases from 6 months to 10 years, the rate of recurrence was 6.07% (12/198).

CONCLUSIONS

Treatment of BCS need to get a corrective diagnosis and classification at first, then select corrective methods of treatment based on different pathological change of IVC and main hepatic vein.

Initial imaging analysis of Budd-Chiari syndrome in Henan province of China: most cases have combined inferior vena cava and hepatic veins involvement

AIM

To evaluate the type of venous involvement in Chinese Budd-Chiari syndrome (BCS) patients and the relative diagnostic accuracy of the different imaging modalities.

METHODS

Using digital subtraction angiography (DSA) as a reference standard, color Doppler ultrasound (CDUS), computed tomography angiography (CTA), and magnetic resonance angiography (MRA) were performed on 338 patients with BCS. We analyzed the course of the main and any accessory hepatic veins (HVs) and the inferior vena cava (IVC) to assess the etiology of obstructed segments and diagnostic accuracy of CDUS, CTA and MRA.

RESULTS

Among the 338 cases, there were 8 cases (2.4%) of isolated IVC membranous obstruction, 45 cases (13.3%) of isolated HV occlusion, and 285 cases (84.3%) with both IVC membranous obstruction and HV occlusion. Comparing with DSA, CDUS, CTA had a diagnostic accuracy of 89.3% and 80.2% in detecting BCS, and 83.4% of cases correctly correlated by MRA.

CONCLUSION

In Henan Province, most patients with BCS have complex lesions combining IVC and HV involvement. The combination of CDUS and CTA or MRI is useful for diagnosis of BCS and guiding therapy.

[Predictive value of five prognostic models for Budd-Chiari syndrome in China]

OBJECTIVE

To compare the predictive value of 5 prognostic models (Child-Pugh scoring, Clichy prognostic index [PI], New Clichy PI, Rotterdam BCS index, and BCS-TIPS PI) for Budd-Chiari syndrome (BCS) in China.

METHODS

The clinical data of 123 patients with BCS were retrospectively analyzed, among whom 99 survived and 24 died. The indices of the 5 prognostic models were respectively calculated, and each index was compared by F-test between the survival and death groups. The area under curve (AUC), sensitivity, and specificity of the models were computed and analyzed by receiver-operator characteristic (ROC) curve.

RESULTS

The indices of Child-Pugh, Clichy, New Clichy and Rotterdam BCS Index models in the death group (8.792∓2.0, 5.924∓0.783, 5.695∓1.81, and 0.615∓1.133, respectively) were significantly higher than those in the survival group (7.141∓1.443, 5.221∓0.834, 3.981∓1.033, and -0.148∓0.896, respectively, P<0.01), and only BCS-TIPS model had no significant difference between the two groups (P>0.05). The AUC of the 5 indices were 0.738, 0.720, 0.776, 0.721, and 0.502, with Youden indices of 0.370, 0.410, 0.439, 0.473, and 0.051, respectively.

CONCLUSION

Child-Pugh scoring, Clichy PI, New Clichy PI, and Rotterdam BCS Index models can distinguish survival from death in BCS patients in China. New Clichy PI has the highest predictive value and is suitable for use in China, whereas the other models have relatively low predictive values, among which BCS-TIPS model is not advisable. Meanwhile effort should be made to establish a prognostic model for BCS in China.

[Budd-Chiari syndrome (case report)]

Budd-Chiari syndrome is a rare disease defined by the obstruction of hepatic venous outflow anywhere from the small hepatic veins to the junction of the inferior vena cava and the right atrium. This syndrome is uncommon in children. The article presents a case report of chronic refractory Budd-Chiari syndrome with a leading ascites in 16 years adolescent, which required surgical intervention--transjugular intrahepatic porta systemic shunt. As this syndrome is uncommon in pediatric practice, complex differential diagnostic search and delays in the diagnosis are frequent. This case report emphasizes the importance of a high index of suspicion in the diagnosis of pediatric Budd-Chiari syndrome and highlights the importance of early referral to a specialized pediatric unit for the further treatment.