Budd-Chiari syndrome: spectrum of imaging findings

Diagnosis and treatment guidelines for aberrant portal hemodynamics: The Aberrant Portal Hemodynamics Study Group supported by the Ministry of Health, Labor and Welfare of Japan

Idiopathic portal hypertension (IPH), causing aberrant portal hemodynamics, is a disease with an as yet unidentified cause and no established treatment protocol. The Japanese research group on IPH in Japan was set up in 1975 by the Ministry of Health, Labor and Welfare. Extrahepatic portal obstruction and Budd-Chiari syndrome (BCS) have since been added to the group's research subjects. The aims of the research group are to accurately evaluate the current status of the three diseases in Japan, elucidate their etiology and pathogenesis, and develop new treatments. Due to the long-term efforts of the Japanese research group, aberrant portal hemodynamics has been investigated in a variety of aspects, from epidemiological and pathological studies to molecular biology analyses. As a result, it has been shown that there are abnormal genes in the liver, specific for IPH. In addition, pathological findings of BCS were internationally compared and the difference in findings between Japan and Europe (or North America) has been clarified. Furthermore, it was found that complication rates of hepatocellular carcinoma in BCS were higher in Japan. Based on the research, "Diagnosis and treatment of aberrant portal hemodynamics (2001)", including diagnostic criteria for aberrant portal hemodynamics, was published in 2001. In 2013, it was revised to "Diagnosis and treatment guidelines for aberrant portal hemodynamics (2013)" after the incorporation of diagnosis and treatment in accordance with its current status.

Combined hepatocellular-cholangiocarcinoma with stem cell features, cholangiolocellular subtype after inferior vena cava stent placement for a patient with Budd-Chiari syndrome

We report a case of combined hepatocellular-cholangiocarcinoma with stem cell features, cholangiolocellular subtype arising about 15 years after placement of an inferior vena cava stent for primary Budd–Chiari syndrome. Pre-surgical differentiation of the tumor from hepatocellular carcinoma was difficult because of elevated levels of alpha-fetoprotein and hypervascularity in the arterial phase. Histopathological examination revealed atypical cells forming ductal and alveolar structures showing a vague border with the surrounding liver. Immunostaining showed positive results for epithelial membrane antigen, mainly localized to the apical surface of the tubules, representing a characteristic finding for combined hepatocellular-cholangiocarcinoma with stem cell features, cholangiolocellular subtype. Combined hepatocellular-cholangiocarcinoma with stem cell features arising in the liver with hepatic damage from Budd–Chiari syndrome is not common, but diagnosis is important to manage the malignancy, which shows different clinical behaviors from hepatocellular carcinoma.

Good Clinical Outcomes in Budd-Chiari Syndrome with Hepatic Vein Occlusion

BACKGROUND

Budd-Chiari syndrome (BCS) with hepatic vein (HV) occlusion is manifested by severe liver damage in acute cases and esophageal variceal bleeding or refractory ascites in chronic cases, which is difficult to differentiate from cirrhotic portal hypertension.

AIMS

To evaluate the clinical efficacy and safety of HV angioplasty and transjugular intrahepatic portosystemic shunt (TIPS) in the treatment of BCS with HV occlusion.

METHODS

Between May 1995 and December 2014, 60 patients with HV occlusive BCS underwent HV angioplasty or TIPS. BCS was subacute or chronic in 55 patients and acute in 5 patients. HV angioplasty was performed in 18 patients with HV occlusion, combined HV and IVC angioplasty in 9 patients with HV and IVC occlusion, TIPS in 12 patients with HV occlusion, and modified TIPS in 21 patients with extensive HV occlusion.

RESULTS

The interventional procedure was successfully performed in all 60 patients. The portal pressure decreased from 41.23 ± 10.46 cmH2O preoperatively to 26.68 ± 6.46 cmH2O postoperatively, while the portal flow velocity increased from 14.31 ± 10.43 to 52.16 ± 13.68 cm/s in patients undergoing TIPS or modified TIPS. During hospitalization, two patients died from hepatic failure, and acute shunt occlusion occurred in two other patients during subsequent treatment with repeated intervention. During 82.25 ± 46.16 months of follow-up, three patients underwent re-intervention with a stenotic shunt, and other three with repeated dilation of the stenotic HV.

CONCLUSION

HV angioplasty and TIPS yield excellent long-term outcomes in patients with HV occlusive BCS.

Comparison of 3.0T MRI with 3D LAVA sequence and digital subtraction angiography for the assessment of accessory hepatic veins in Budd-Chiari syndrome

PURPOSE

To compare 3D liver acceleration volume acquisition (LAVA) and digital subtraction angiography (DSA) for evaluating the presence of accessory hepatic veins (AHV) in Budd-Chiari syndrome (BCS).

MATERIALS AND METHODS

This was a retrospective study in 228 patients with BCS who underwent 3.0T magnetic resonance imaging (MRI) with the 3D LAVA sequence. Two reviewers noted AHV: openings located in the inferior vena cava (IVC), caliber, and the angle of entering into the IVC. MRI results were compared to DSA. Kappa statistics were calculated to quantify intrareader variability in detecting AHVs.

RESULTS

On MRI, 63 patients demonstrated no AHV on LAVA images, 70 had one AHV, 62 had two AHVs, 26 patients had three AHVs, six patients had four AHVs, and one patient had five AHVs (P < 0.05 vs. DSA). The mean caliber of the AHVs was 8.3 ± 4.0 mm compared to 9.9 ± 3.2 for DSA (P < 0.001). Among the 301 AHVs, there were 140 with acute angles (46.5%), 71 with right angles (23.6%), and 90 with obtuse angles (29.8%). The prevalence of AHVs on DSA was 54.8% (125/228), while MRI demonstrated 301 AHVs in 165 patients, for a prevalence of 72.4% (165/228) compared to 54.8% for DSA (P = 0.001). The two methods were concordant in only 116/228 (50.9%) patients. The kappa coefficient demonstrated good intrareader consistency for all documented MRI findings of AHVs (κ = 0.626 for caliber and κ = 0.65 for angles).

CONCLUSION

More AHVs were visible on MRI LAVA sequences than on conventional DSA.

LEVEL OF EVIDENCE

4 J. Magn. Reson. Imaging 2017;45:401-409.

Budd-Chiari syndrome: a prospective analysis of hepatic vein obstruction on ultrasonography, multidetector-row computed tomography and MR imaging

PURPOSE

The goal of this study was to prospectively describe the imaging presentation of hepatic vein (HV) obstruction in patients with Budd-Chiari syndrome (BCS) on duplex and color Doppler ultrasonography (DCD-US), multidetector-row computed tomography (MDCT) and magnetic resonance imaging (MRI).

MATERIALS AND METHODS

A total of 176 patients with primary BCS (mean age, 33 years; 101 women) were prospectively included. BCS diagnosis was made by direct visualization of HV and/or upper portion of the inferior vena cava (IVC) obstruction on DCD-US and/or MDCT and/or MRI. Location (right, middle, and left HV), type (thrombus, stenosis, or both), and age (recent vs. long-standing) of HV obstruction were described on each imaging examination.

RESULTS

HV obstruction was a constant (100%) finding and associated with IVC abnormalities in 51/176 (28.98%) patients. Obstruction of the three HVs was present in 158/176 (89.77%) patients. The prevalences of right, middle, and left HV thrombus were 151/169 (89.35%), 146/169 (86.39%), and 111/169 (65.68%), respectively. Long-standing HV thrombus was observed in more than 92% of patients on the three imaging methods. Agreement between DCD-US, MDCT, and MRI was perfect in the identification of long-standing HV thrombus (κ = 0.9); this agreement was slight to moderate in revealing the type of HV abnormality (i.e., fibrotic cord and non-visible HV).

CONCLUSION

Our results indicate that BCS is a chronic and insidious disease, more often discovered at an advanced stage. These results should warrant further evaluation of screening strategies in patients with risk factors for BCS to identify the disease at an early stage.

Historical perspective: eponyms of vascular radiology

Eponyms are ubiquitous throughout the medical literature, especially the radiology lexicon. In particular, vascular radiology is replete with dozens of eponyms named after pathologic and anatomic features and various medical devices. Several disease processes are known exclusively by their eponyms or by both their eponyms and their descriptive names. Although some authors advocate abandoning eponyms in favor of more descriptive terms, the established history and common use of eponyms make it unlikely that they will disappear from the vocabulary. Radiologists should be familiar with both the eponymous and descriptive names of disease processes to ensure effective communication and prevent erroneous identification. Study of these eponyms provides information about these disease processes and other medical knowledge for use in daily practice. In addition, biographic information about the pertinent physicians can yield insights into the sometimes surprising origins of these eponyms. The authors provide biographic sketches of these physicians and discuss the clinical relevance of the anatomic features, malformations, and syndromes that bear their names.

Serum Iodine Is Increased in Subjects Having Budd-Chiari Syndrome

This study was performed to investigate the status of serum iodine concentration among the Budd-Chiari syndrome (BCS) patients and its effect on thyroid hormone. The study group serum specimens were collected from 233 BCS patients and 60 healthy people. Serum iodine was analyzed with the Sandell-Kolthoff method, and the ELISA method was used to detect thyroid function: TSH, T3, T4, FT3, and FT4. The serum iodine level of patients with BCS was 316.7 ± 256.8 μg/L, greatly higher than 76.3 ± 25.7 μg/L of serum iodine for control group (p < 0.001), but with no significant difference among different types of BCS. There were no statistically significant differences in thyroid hormone levels (TSH, T3, T4, FT3, and FT4) between people with BCS and control group, although the TSH level of BCS group is slightly higher than that of normal control group. This study demonstrates that iodine may be related to the pathogenesis of BCS and needs to be paid more attention.

Imaging Diagnosis of Splanchnic Venous Thrombosis

Splanchnic vein thrombosis (SVT) is a broad term that includes Budd-Chiari syndrome and occlusion of veins that constitute the portal venous system. Due to the common risk factors involved in the pathogenesis of these clinically distinct disorders, concurrent involvement of two different regions is quite common. In acute and subacute SVT, the symptoms may overlap with a variety of other abdominal emergencies while in chronic SVT, the extent of portal hypertension and its attendant complications determine the clinical course. As a result, clinical diagnosis is often difficult and is frequently reliant on imaging. Tremendous improvements in vascular imaging in recent years have ensured that this once rare entity is being increasingly detected. Treatment of acute SVT requires immediate anticoagulation. Transcatheter thrombolysis or transjugular intrahepatic portosystemic shunt is used in the event of clinical deterioration. In cases with peritonitis, immediate laparotomy and bowel resection may be required for irreversible bowel ischemia. In chronic SVT, the underlying cause should be identified and treated. The imaging manifestations of the clinical syndromes resulting from SVT are comprehensively discussed here along with a brief review of the relevant clinical features and therapeutic approach.

A Rare Presentation of an Entrapment in a Liver Transplant Candidate Depicted by MDCT Angiography

Hypertrophic caudate lobe veins can mimic a normal venous configuration. In cases of multiple vascular collaterals, Doppler evaluations must be conducted, and the flow direction of these veins as well as the IVC should be evaluated. If the flow in the IVC is reversed, Budd-Chiari syndrome should be suspected; moreover, at the supra diaphragmatic level, which may be considered a blind spot, particularly for radiologists, a web should be searched for in the area where the IVC opens into the right atrium. In this study, we present the unique findings of multidetector computed tomography (MDCT) angiography for a liver transplant candidate with Budd-Chiari syndrome caused by a web in the proximal IVC.

Multiple hyperplastic nodular lesions of the liver in the Budd-Chari syndrome: a case report and review of published reports

The Budd-Chari syndrome (BCS) is a group of disorders of hepatic vein outflow at various levels from the hepatic veins to inferior vena cave. We describe a 49-year-old man with multiple intrahepatic lesions who had been diagnosed with the BCS. The inferior vena cavography showed hepatic vein occlusion and long-range obstruction of inferior vena cava. The biopsy proved to be hyperplastic nodules, also called large regenerative nodules (LRNs). Both benign regenerative nodules and hepatocellular carcinoma (HCC) appear in patients with BCC; however, published reports about the diagnosis and differential diagnosis are limited. The incidence of HCC in patients with BCS varies greatly depending on geography. This case illustrates that benign nodules can arise in BCS patients. We reviewed published reports and speculated that medical procedures leading to portal perfusion decrease may be associated with the development of these hyperplastic nodules.

Budd-Chiari Syndrome Caused by TIPS Malposition: A Case Report

Budd-Chiari syndrome refers to hepatic pathology secondary to diminished venous outflow, most commonly associated with venothrombotic disease. Clinically, patients with Budd-Chiari present with hepatomegaly, ascites, abdominal distension, and pain. On imaging, Budd-Chiari syndrome is hallmarked by occluded IVC and or hepatic veins, caudate lobe enlargement, heterogeneous liver enhancement, intrahepatic collaterals, and hypervascular nodules. Etiopathological factors for Budd-Chiari syndrome include several systemic thrombotic and nonthrombotic conditions that can cause venous outflow obstruction at hepatic veins and/or IVC. While the transjugular intrahepatic portosystemic shunt (TIPS) is used as a treatment option for Budd-Chiari syndrome, Budd-Chiari syndrome is not a well-known complication of TIPS procedure. We report a case of Budd-Chiari syndrome that occurred in a transplanted cirrhotic liver from malpositioned proximal portion of the TIPS in IVC causing occlusion of the ostia of hepatic veins which was subsequently diagnosed on contrast-enhanced CT.

Magnetic resonance imaging in cirrhosis: what's new?

Cirrhosis is the main risk factor for the development of hepatocellular carcinoma (HCC). The major causative factors of cirrhosis in the United States and Europe are chronic hepatitis C infection and excessive alcohol consumption with nonalcoholic steatohepatitis emerging as another important risk factor. Magnetic resonance imaging is the most sensitive imaging technique for the diagnosis of HCC, and the sensitivity can be further improved with the use of diffusion-weighted imaging and hepatocyte-specific contrast agents. The combination of arterial phase hyperenhancement, venous or delayed phase hypointensity "washout feature," and capsular enhancement are features highly specific for HCC with reported specificities of 96% and higher. When these features are present in a mass in the cirrhotic liver, confirmatory biopsy to establish the diagnosis of HCC is not necessary. Other tumors, such as cholangiocarcinoma, sometimes occur in the cirrhotic at a much lower rate than HCC and can mimic HCC, as do other benign lesions such as perfusion abnormalities. In this article, we discuss the imaging features of cirrhosis and HCC, the role of magnetic resonance imaging in the diagnosis of HCC and other benign and malignant lesions that occur in the cirrhotic liver, and the issue of nonspecific arterially hyperenhancing nodules often seen in cirrhosis.

Case report: maximum-intensity projection and minimum-intensity projection of computed tomography are helpful in the diagnosis of Budd-Chiari syndrome in complicated liver cirrhosis

BACKGROUND

Early detection of Budd-Chiari syndrome (BCS) to give the appropriate therapy in time is crucial. Angiography remains the golden standard to diagnose BCS. However, to establish the diagnosis of BCS in complicated cirrhotic patients remains a challenge. We used maximum intensity projection (Max IP) and minimum intensity projection (Min IP) from computed tomographic (CT) images to detect this syndrome in such a patient.

CASE REPORT

A 55-year-old man with a history of chronic hepatitis B infection and alcoholism had undergone previously a left lateral segmentectomy for hepatic epitheloid angiomyolipoma (4.6 × 3.5 × 3.3 cm) with a concomitant splenectomy. Liver decompensation with intractable ascites and jaundice occurred 4 months later. The reformed images of the venous phase of enhanced CT images with Max IP and Min IP showed middle hepatic vein thrombosis. He then underwent a living-related donor liver transplantation with a right liver graft from his daughter. Intraoperatively, we noted thrombosis of his middle hepatic vein protruding into inferior vena cava. The postoperative course was unevenful. Microscopic findings revealed micronodular cirrhosis with mixed inflammation in the portal areas. Some liver lobules exhibited congestion and sinusoidal dilation compatible with venous occlusion clinically.

CONCLUSIONS

We recommend Max IP and Min IP of CT images as simple and effective techniques to establish the diagnosis of BCS, especially in complicated cirrhotic patients, thereby avoiding invasive interventional procedures.

Hepatocellular carcinoma associated with Budd-Chiari syndrome: imaging features and transcatheter arterial chemoembolization

Background

Budd–Chiari syndrome (BCS) often leads to hepatocellular carcinoma (HCC). Transcatheter arterial chemoembolization (TACE) has been increasingly used to treat BCS patients with HCC. The purposes of this study were to illustrate imaging features in BCS patients with HCC, and to analyze the effects of TACE on BCS patients with HCC.

Methods

246 consecutive patients with primary BCS were retrospectively studied. 14 BCS patients with HCC were included in this study. BCS were treated with angioplasty and/or stenting, and HCC were managed with TACE. Imaging features on ultrasonography, CT, MRI, and angiography and the serum AFP level were analyzed.

Results

Inferior vena cava block and stricture of hepatic venous outflow tract more frequently occurred. Portal vein invasion was found in only 2 patients (14.2%). Imaging studies showed that most nodules of HCC were near the edge of liver, irregular, more than 3 cm in diameter, heterogeneous mass and solitary (≤3 nodules). HCC in patients associated with BCS was isointense or hypointense in nonenhanced CT images, and exhibited heterogeneous enhancement during the arterial phase and washout during the portal venous phase on enhanced CT and MRI. The serum AFP level significantly declined after TACE treatment.

Conclusions

BCS patients with inferior vena cava block and stricture of hepatic venous outflow tract seems to be associated with HCC. A single, large, irregular nodule with a peripheral location appears to be HCC. TACE can effectively treat HCC in BCS patients.

Budd-Chiari syndrome

OBJECTIVE

Budd-Chiari syndrome (BCS) is an uncommon condition characterized by obstruction of the hepatic venous outflow tract. Presentation may vary from a completely asymptomatic condition to fulminant liver failure. BCS is an example of postsinusoidal portal hypertension. The management can be divided into three main categories: medical, surgical, and endovascular. The purpose of this article is to present an overall perspective of the problem, diagnosis, and management.

CONCLUSION

BCS requires accurate, prompt diagnosis and aggressive therapy. Treatment will vary depending on the clinical presentation, cause, and anatomic location of the problem. Patients with BCS are probably best treated in tertiary care centers where liver transplantation is available.

Perfusion and parenchymal changes related to vascular alterations of the liver

Imaging plays a significant role in the diagnosis of vascular abnormalities of the liver and sometimes provides the only clue to the correct diagnosis. With advances of imaging techniques and multiphasic acquisition of liver imaging, various perfusion changes are frequently encountered. Correct imaging diagnosis of significant vascular diseases can prompt appropriate work-up and timely management. Accurate differentiation of clinically insignificant perfusion phenomena from clinically significant findings including neoplastic conditions and in the setting of post-transplantation is essential. This pictorial essay illustrates various perfusion and parenchymal changes associated with portal venous inflow, hepatic venous outflow, and non-portal venous third inflow and describes brief background pathophysiology and differential points.

Emergency radiology eponyms: part 2--Naclerio's V sign to Fournier gangrene

An eponym is a name based on the name of a person, frequently as a means to honor him/her, and it can be used to concisely communicate or summarize a complex abnormality or injury. However, inappropriate use of an eponym may lead to potentially dangerous miscommunication. Moreover, an eponym may honor the incorrect person or a person who falls into disrepute. Despite their limitations, eponyms are still widespread in medicine. Many commonly used eponyms applied to extremity fractures should be familiar to most emergency radiologists and have been previously reported. Yet, a number of non-extremity eponyms can be encountered in an emergency radiology practice as well. This other group of eponyms encompasses a spectrum of traumatic and nontraumatic pathology. In this second part of a two-part series, the authors discuss a number of non-extremity emergency radiology eponyms, including relevant clinical and imaging features, as well biographical information of the eponyms' namesakes.

Abdominal thromboses of splanchnic, renal and ovarian veins

Thromboses of abdominal veins outside the iliac-caval axis are rare but clinically relevant. Early deaths after splanchnic vein thrombosis occur in 5-30% of cases. Sequelae can be liver failure or bowel infarction after splanchnic vein thrombosis, renal insufficiency after renal vein thrombosis, ovarian infarction after ovarian vein thrombosis. Local cancer or infections are rare in Budd-Chiari syndrome, and common for other sites. Inherited thrombophilia is detected in 30-50% of patients. Myeloproliferative neoplasms are the main cause of splanchnic vein thrombosis: 20-50% of patients have an overt myeloproliferative neoplasm and/or carry the molecular marker JAK2 V617F. Renal vein thrombosis is closely related to nephrotic syndrome; finally, ovarian vein thrombosis can complicate puerperium. Heparin is used for acute treatment, sometimes in conjunction with systemic or local thrombolysis. Vitamin K-antagonists are recommended for 3-6 months, and long-term in patients with Budd-Chiari syndrome, unprovoked splanchnic vein thrombosis, or renal vein thrombosis with a permanent prothrombotic state such as nephrotic syndrome.

Spectrum of imaging in Budd Chiari syndrome

Budd Chiari syndrome is an uncommon heterogeneous group of disorders which occur due to obstruction at any level from the hepatic venules to the junction of inferior vena cava and right atrium of heart which has significant morbidity and mortality. An early diagnosis of the disease is required for appropriate treatment. Due to the diffuse nature of the disease, normal biopsy findings do not exclude the disease. Proper clinical history and imaging are essential for definitive diagnosis. In this pictorial essay, we discuss the imaging spectrum of Budd Chiari syndrome.

Imaging of acute conditions affecting the hepatic vasculature

Liver imaging primarily consists of evaluating the parenchyma and biliary system. However, the liver has a rich, complex vascularity which can also be affected by numerous disease processes. By considering disease processes that primarily affect the hepatic veins, portal veins, and hepatic arteries, an anatomy-based approach of hepatic vascular diseases can be applied to image interpretation to allow rapid diagnosis and prompt initiation of treatment. Computed tomography, magnetic resonance imaging, and ultrasound are all effectively used to evaluate the liver and can play complimentary roles. In this article, the key imaging findings of acute conditions affecting the hepatic veins (passive congestion, acute thrombosis/Budd-Chiari, stenosis), portal veins (thrombosis, phlebitis, stenosis), hepatic arteries (laceration, pseudoaneurysm, thrombosis), and arteriovenous structures (hereditary hemorrhagic telangiectasis, arteriovenous fistula) will be reviewed.

Living-donor liver transplant in 3 patients with Budd-Chiari syndrome: case report

Budd-Chiari syndrome is a rare but life-threatening disorder characterized by obstruction of the hepatic venous outflow. Treatment depends on the underlying cause, the location, and extent of the obstruction, and the functional capacity of the liver. A stepwise therapeutic approach is commonly accepted. When all other therapy options are unsuccessful, or in case of end-stage liver disease, transplant should be considered. We present case reports of 3 patients with Budd-Chiari syndrome who underwent living-donor liver transplant. Characteristic features of Budd-Chiari syndrome, diagnostic and therapeutic interventions, complications, and overall outcomes are discussed. We believe that when a deceased donor graft is unavailable, a living-donor liver transplant can be a safe option for patients with end-stage liver disease associated with Budd-Chiari syndrome.

Progress in research of molecular markers for hepatic oval cells Li-Ping Sun, Qiao-Xia Tong, Sheng-Hua Jie

Portal hypertension is defined as an increase in blood pressure in the veins of the portal system and extensive formation of portal-systemic communicating branches, which results from a blockage in the portal blood flow or abnormal blood increment. Generally, cirrhotic portal hypertension is common more than non-cirrhotic portal hypertension, but the latter is caused by a group of diseases, such as idiopathic portal hypertension(IPH), pancreatic sinistral portal hypertension (PSPH), cavernous transformation of the portal vein (CTPV), congenital hepatic fibrosis (CHF), Budd-Chiari syndrome (BCS), hepatic sinusoidal obstruction syndrome (SOS), portal vein thrombosis (PVT), myeloproliferative disease (MLD), hepatic amyloidosis, and hemochromatosis (HC). This paper reviews the rare causes of portal hypertension and their diagnosis.

Diagnosis of Budd-Chiari syndrome: three-dimensional dynamic contrast enhanced magnetic resonance angiography

OBJECTIVE

To investigate the characteristics and diagnostic value of three-dimensional contrast-enhanced magnetic resonance angiography (3D CE-MRA) in the diagnosis of Budd-Chiari syndrome (BCS).

METHODS

One hundred thirty-three BCS patients underwent 3D CE-MRA, 64 patients had primary BCS, and 69 had secondary BCS.

RESULTS

Fifty five cases (41.4%) showed a segmental stenosis of the inferior vena cava, 9 cases (6.8%) a membranous obstruction of the inferior vena cava, 5 cases (3.8%) an unobstructed inferior vena cava and hepatic veno-occlusive condition, 16 cases (12.0%) an inferior vena cava stenosis and hepatic veno-occlusive disease, and 48 cases (36.1%) an intraluminal filling defect in the inferior vena cava. In 52 cases (39.1%), collateral blood vessels were formed, with deep, medium, and shallow portal veins and intrahepatic collateral veins in 88 groups. Among these, 41 (46.6%) had deep venous collateral channels, 24 (27.3%) had medium venous collateral channels, 9 (10.2%) had superficial venous collateral channels, 5 (5.7%) had portal vein collateral channels, and 9 (10.2%) had intrahepatic venous collateral channels.

CONCLUSION

3D CE-MRA is important in the clinical diagnosis and treatment planning of BCS and displays hepatic veins, the inferior vena cava system, and collateral vessels.

Acoustic radiation force impulse elastography and contrast-enhanced sonography of sinusoidal obstructive syndrome (Veno-occlusive Disease): preliminary results

We report quantitative liver acoustic radiation force impulse (ARFI) elastographic findings in 2 cases of sinusoidal obstructive syndrome and liver contrast-enhanced sonographic features in one of these cases. To our knowledge, findings in this condition from these techniques have not been reported previously. Acoustic radiation force impulse elastography showed median high shear wave velocities (case 1, 2.75 m/s; case 2, 2.58 m/s) that normalized after specific treatment for sinusoidal obstructive syndrome; therefore, ARFI elastography provided quantitative information that helped diagnose this condition as well as monitor the response to treatment. Contrast-enhanced sonographic findings in one of the cases showed patchy liver enhancement that correlated with the high-velocity patchy distribution on ARFI elastography in that case and enhanced multidetector row computed tomographic findings in the other case. This contrast-enhanced sonographic pattern progressively normalized during follow-up after specific treatment. The elastographic features in both cases and contrast-enhanced sonographic features in one of them contributed to early diagnosis and follow-up of sinusoidal obstructive syndrome in both patients. Further prospective studies are necessary to define the role of ARFI elastography and contrast-enhanced sonography in the early diagnosis and clinical follow-up of this condition.

Outcome of non surgical hepatic decompression procedures in Egyptian patients with Budd-Chiari

AIM: To evaluate outcome of patients with Budd-Chiari syndrome after balloon angioplasty ± stenting or transjugular intrahepatic portosystemic shunt (TIPS).

METHODS: Twenty five patients with Budd-Chiari syndrome admitted to Ain Shams University Hospitals, Tropical Medicine Department were included. Twelve patients (48%) with short segment occlusion were candidates for angioplasty; with stenting in ten cases and without stenting in two. Thirteen patients (52%) had Transjugular Intrahepatic Portosystemic Shunt. Patients were followed up for 12-32 mo.

RESULTS: Patency rate in patients who underwent angioplasty ± stenting was 83.3% at one year and at end of follow up. The need of revision was 41.6% with one year survival of 100%, dropped to 91.6% at end of follow up. In patients who had Transjugular Intrahepatic Portosystemic Shunt, patency rate was 92.3% at one year, dropped to 84.6% at end of follow up. The need of revision was 38.4% with one year and end of follow up survival of 100%. Patients with patent shunts showed marked improvement compared to those with occluded shunts.

CONCLUSION: Morbidity and mortality following angioplasty ± stenting and TIPS are low with satisfactory outcome. Proper patient selection and management of shunt dysfunction are crucial in improvement.

A case of Budd-Chiari syndrome: Gd-EOB-DTPA-enhanced MR findings

Budd-Chiari syndrome (BCS) is a rare disorder caused by the obstruction of hepatic venous outflow, leading to sinusoidal congestion, ischemic injury to liver cells and portal hypertension. Long-term survival largely depends on whether hepatocellular carcinoma occurs. A recently available liver-specific contrast medium, gadolinium-ethoxybenzyl-diethylenetriamine penta-acetic acid (Gd-EOB-DTPA), reportedly has high diagnostic capability for detection of malignant liver tumors. However, there has been no report of the sue of Gd-EOB-DTPA-enhanced magnetic resonance imaging (MRI) for BCS. We present a case of chronic BCS who underwent both gadopentetate dimeglumine (Gd-DTPA) and Gd-EOB-DTPA-enhanced MRI. Hepatic congestion and edema were seen as slightly hypointense areas on Gd-EOB-DTPA-enhanced hepatobiliary-phase images, although these areas were observed as slightly hyperintense on previously obtained Gd-DTPA-enhanced delayed-phase image. Reduced uptake of Gd-EOB-DTPA by hepatocytes in the region of congestion or edema may account for this difference, which should be recognized in image interpretations.

Paediatric chronic liver diseases: how to investigate and follow up? Role of imaging in the diagnosis of fibrosis

Chronic liver diseases are rare in children, but encompass a wide spectrum of disorders that may all be complicated by liver fibrosis and therefore by portal hypertension. They may be classified according to the level of portal flow obstruction: prehepatic, intrahepatic or suprahepatic. Most of them, except presinusoidal diseases, may progress to cirrhosis that carries additional risks of impaired liver function and development of hepatocellular carcinoma. Imaging plays an important role in guiding the diagnosis and biopsy and for follow-up during treatment. US, with high-frequency transducers and Doppler, is the first modality of choice, directs the rest of the investigations and guides interventional radiology. MDCT has made great progress and has replaced angiography for diagnostic purposes. MRI is indicated for parenchyma and nodule characterization and for biliary tract evaluation. To avoid liver biopsy, several elasticity imaging techniques have been developed and have to be evaluated for accuracy and convenience in children. The role of each modality with main imaging findings is described in extrahepatic portal vein obstruction, hepatoportal sclerosis, congenital hepatic fibrosis, cirrhosis and Budd-Chiari syndrome.

Hepatic caudate vein in Budd-Chiari syndrome: depiction by using magnetic resonance imaging

OBJECTIVE

To study the visibility of the caudate vein and its diameter on MR imaging in healthy people and in patients with Budd-Chiari syndrome.

MATERIALS AND METHODS

In this study there were 14 patients with Budd-Chiari syndrome and 54 healthy subjects without hepatic lesion or liver disease, all of whom had upper abdominal enhanced MRI. The visibility of the caudate vein and its diameter on MR images was compared between Budd-Chiari patients and healthy subjects, and among Budd-Chiari patients, the correlation between the visibility of caudate vein and extrahepatic collaterals were compared.

RESULTS

Caudate vein was noted in 64% of patients with Budd-Chiari syndrome and in 7% of healthy subjects (P=0.000). The diameter of the caudate vein visualized on MR imaging in Budd-Chiari syndrome was significantly larger than that in healthy group (7.3±3.9 mm vs 2.6±0.6 mm, P=0.037). Among Budd-Chiari patients, both caudate vein and extrahepatic collateral veins were noted in 9 patients, only extrahepatic collateral veins were noted in 4 patients and neither caudate vein nor extrahepatic collateral veins were noted in 1 patient. No correlation was found between the visibility of caudate vein and that of extrahepatic collateral vein in patients with Budd-Chiari (P=0.375).

CONCLUSION

Gadolinium enhanced dynamic MR imaging can visualize hepatic caudate vein frequently. The visibility and dilation of hepatic caudate veins on MR imaging in Budd-Chiari syndrome were more frequent than in control subjects. MR depiction of a caudate vein may help differentiate Budd-Chiari from cirrhosis.

Risk factors for chemotherapy-associated liver injuries: A multivariate analysis of a group of 146 patients with colorectal metastases

BACKGROUND

Chemotherapy for colorectal liver metastases (CLM) may be associated with pathologic changes to the liver parenchyma, possibly increasing the risk of surgery. The aim of this study was to determine the risk factors for chemotherapy-associated liver injuries (CALI).

METHODS

From 1998 to 2006, 146 patients underwent a liver resection for CLM within 3 months of preoperative chemotherapy. CALI were defined as follows: steatosis > or =30%, or steatohepatitis, or moderate or severe sinusoidal lesions. Univariate and multivariate analysis were used to examine the relationship between CALI and 36 other preoperative factors.

RESULTS

Pathologic examination showed CALI in 74/146 patients (51%), including sinusoidal lesions (n = 50), steatosis > or = 30% (n = 32), and steatohepatitis (n = 15). Twenty-three patients had overlapping CALI. In multivariate analysis, BMI > 27 (P = .002), hyperglycemia > 7 mmol/l (P = .006), and an interval between chemotherapy and surgery < 4 weeks (P = .011) were independent risk factors for CALI, whereas aspirin intake was associated with reduced risk of CALI (P = .002). In multivariate analysis, synchronous metastases (P = .015), unresectable liver metastases at diagnosis (P = .034), GGT plasma level > 1.5N (P = .028), and oxaliplatin-based chemotherapy (P < .01) were risk factors for sinusoidal lesions. Aspirin intake was associated with reduced risk for sinusoidal lesions (P = .03). In multivariate analysis, BMI > 27 (P = .026) was the only risk factor for steatosis or steatohepatitis.

CONCLUSION

In patients with CLM, there are few preoperative risk factors for CALI. In patients treated by oxaliplatin-based chemotherapy, aspirin intake appears to be associated with a reduced risk of sinusoidal lesions and should be tested in a randomized phase II study.

Regenerative nodules in patients with chronic Budd-Chiari syndrome: a longitudinal study using multiphase contrast-enhanced multidetector CT

OBJECTIVE

Our aim was to evaluate the serial evolution of regenerative nodules in patients with Budd-Chiari syndrome (BCS) treated with portal-systemic shunts, using multiphasic multidetector computed tomography (MDCT).

MATERIALS AND METHODS

Five patients each underwent three MDCT exams over an extended period ranging from 36 to 42 months. Two radiologists in consensus retrospectively reviewed each exam for each patient. Individual nodules were grouped according to size (size I: nodules with diameter < or =15 mm; size II: >15 mm but <30 mm; size III: > or =30 mm), pattern of enhancement (A: homogeneously hypervascular or B: with central scar), and segmental location. Four nodules classified as size II, which increased in size over time, were needle-biopsied.

RESULTS

We detected 61 nodules at the first exam, 66 nodules at the second exam (7 nodules disappeared and 12 new nodules), and 85 nodules at the third exam (8 disappeared and 27 new) for a total of 212 findings. Nodules were mostly found in the right hepatic lobe. Fourteen of the 15 nodules that disappeared over time were size I and enhancement pattern A. At unenhanced MDCT, 204 (96%) of the 212 findings were isodense. Overall, 100 nodules, including the 61 initially detected, were considered newly diagnosed; of these 84 (84%) were size I and pattern A. Of 57 nodules considered size I and pattern A at the first or second exam, 24 (42%) changed to pattern B at the third exam and either size II (n=18) or III (n=6). The four biopsied nodules were each confirmed as benign regenerative nodule. No patient developed HCC at 5-year follow-up period.

CONCLUSION

Hepatic nodules in BCS patients not only increase in number over time but may also increase in size and develop a central scar.

Portal vein thrombosis and budd-Chiari syndrome

Venous thrombosis results from the convergence of vessel wall injury and/or venous stasis, known as local triggering factors, and the occurrence of acquired and/or inherited thrombophilia, also known as systemic prothrombotic risk factors. Portal vein thrombosis (PVT) and Budd-Chiari syndrome (BCS) are caused by thrombosis and/or obstruction of the extrahepatic portal veins and the hepatic venous outflow tract, respectively. Several divergent prothrombotic disorders may underlie these distinct forms of large vessel thrombosis. While cirrhotic PVT is relatively common, especially in advanced liver disease, noncirrhotic and nontumoral PVT is rare and BCS is of intermediate incidence. In this article, we review pathogenic mechanisms and current concepts of patient management.

CT of nonneoplastic hepatic vascular and perfusion disorders

The unique dual blood supply of the liver (75% portal venous, 25% hepatic arterial) makes multiphase helical computed tomography (CT) a highly suitable technique for hepatic evaluation with imaging in two (arterial and portal venous) or more phases. Multiphase helical CT has become an important tool in the detection and characterization of hepatic tumors. In some situations, hemodynamic changes might mimic neoplastic or inflammatory lesions and evoke diagnostic uncertainty. To confidently identify hepatic conditions such as venous outflow obstruction (Budd-Chiari syndrome), arterioportal shunts, hereditary hemorrhagic telangiectasia (Osler-Weber-Rendu syndrome), peliosis hepatis, passive congestion, and hepatic infarction, radiologists must be familiar with the disease-specific CT appearances and related clinical manifestations.

Two-case analysis of pseudo-Budd-Chiari syndrome

Pseudo-Budd-Chiari syndrome usually occurs in patients with alcoholic liver disease, and its sonographic and radiographic findings were similar to that of Budd-Chiari syndrome. Moreover, venography showed no abnormal changes of inferior vena cava (IVC) and hepatic vein. This paper reports two cases who were admitted to hospital due to abdominal distention and debilitation. After laboratory examinations, Doppler-ultrasound detection, enhanced liver CT scan and IVC angiography, both of them were diagonosed with pseudo-Budd-Chiari syndrome.

Sinusoidal obstructive syndrome diagnosed with superparamagnetic iron oxide-enhanced magnetic resonance imaging in patients with chemotherapy-treated colorectal liver metastases

PURPOSE

To assess the predictive value of superparamagnetic iron oxide (SPIO) -enhanced T2-weighted gradient echo (GRE) imaging to determine the presence and severity of sinusoidal obstructive syndrome (SOS).

PATIENTS AND METHODS

Sixty hepatic resection patients with colorectal metastases treated with chemotherapy underwent unenhanced magnetic resonance imaging (MRI) followed by T2-weighted GRE sequences obtained after SPIO. The images were reviewed in consensus by two experienced observers who determined the presence and severity of linear and reticular hyperintensities, indicating SOS-type liver injury, using a 4-point ordinal scale. Sensitivity, specificity, positive predictive value (PPV), and negative predictive value (NPV) with 95% CIs for the detection of SOS were calculated.

RESULTS

Twenty-four of 60 patients had moderate to severe SOS on MRI. MRI achieved a sensitivity of 87% (95% CI, 66% to 97%), specificity of 89% (95% CI, 75% to 97%), PPV of 83% (95% CI, 63% to 95%), and NPV of 92% (95% CI, 77% to 98%). SOS was never found at surgery or histology in patients whose background liver parenchyma was normal on SPIO-enhanced MRI.

CONCLUSION

SOS is present in a significant proportion of patients with treated colorectal metastases and is effectively detected on SPIO-enhanced T2-weighted GRE images.

Advances in imaging diagnosis of Budd-Chiari syndrome

Budd-Chiari syndrome (BCS) is very easy to be misdiagnosed due to the lack of specificity in clinical manifestation. With the improvement of multiple imaging diagnostic devices and methods, the detection rate of BCS is raised. The noninvasive imaging examination methods, such as ultrasound, multi-slice computed tomography (MSCT), magnetic resonance imaging (MRI), are able to clearly display hepatic vein (HV), inferior vena cave (IVC), and the location and type of stenosis. Therefore, they are useful for the clinical treatment and result observation.

Doppler waveform pattern changes in a patient with primary Budd-Chiari syndrome before and after angioplasty

A 34-year-old woman was admitted for treatment of esophageal varices. Seven years earlier, she had been diagnosed with Budd-Chiari syndrome, and percutaneous transluminal angioplasty (PTA) for right hepatic vein (RHV) stenosis was done. On admission, Doppler sonography showed a flat waveform in the RHV. RHV re-stenosis was confirmed on X-ray sonography. After PTA, the stenosis improved. Heterogeneous liver enhancement on enhanced computed tomography became homogeneous, her esophageal varices became inconspicuous, and the flat Doppler waveform pattern changed to a triphasic pattern. Doppler sonography was very useful for evaluating the effect of angioplasty and to diagnose re-stenosis.

Cirrhosis: CT and MR imaging evaluation

In this article, we present the CT and MR imaging characteristics of the cirrhotic liver. We describe the altered liver morphology in different forms of viral, alcoholic and autoimmune end-stage liver disease. We present the spectrum of imaging findings in portal hypertension, such as splenomegaly, ascites and varices. We describe the patchy and lacelike patterns of fibrosis, along with the focal confluent form. The process of hepatocarcinogenesis is detailed, from regenerative to dysplastic nodules to overt hepatocellular carcinoma. Different types of non-neoplastic focal liver lesions occurring in the cirrhotic liver are discussed, including arterially enhancing nodules, hemangiomas and peribiliary cysts. We show different conditions causing liver morphology changes that can mimic cirrhosis, such as congenital hepatic fibrosis, "pseudo-cirrhosis" due to breast metastases treated with chemotherapy, Budd-Chiari syndrome, sarcoidosis and cavernous transformation of the portal vein.