Liver transplantation for Budd-Chiari syndrome: when is it really necessary?

Case of Budd-Chiari syndrome, an enigma as abdominal tuberculosis in a tubercular endemic country: A case report

Introduction and importance

Bud-Chiari syndrome is an uncommon disease due to obstruction of hepatic venous outflow. Clinical manifestations range from asymptomatic cases to those requiring liver transplants. The study highlights the importance of diagnosing a case of Budd-Chiari syndrome which has been suspected with abdominal tuberculosis where anti-tubercular drugs may themselves damage the liver.

Case presentation

Herein we report a case of 18 years old female presenting with upper abdominal pain along with recurrent abdominal distention, jaundice, and deranged liver function. Also, adenosine deaminase level was raised in both pleural and peritoneal fluids, hence, anti-tubercular treatment was started but could not be continued as she developed adverse reactions to these drugs. CT scan later revealed features suggestive of Budd-Chiari syndrome. Initially, she was managed with balloon angioplasty, but her condition worsened ultimately requiring a liver transplant.

Clinical discussion

Budd Chiari syndrome can present with subtle presentation and since abdominal tuberculosis is very non-specific, the two conditions can be very confusing, particularly in the tubercular endemic region. Detailed clinical assessment along with proper investigations and imaging should be performed for early recognition as both conditions are associated with high morbidity and mortality if not treated timely.

Conclusion

The necessity of careful investigation and consideration of Budd-Chiari syndrome as an important cause of ascites with jaundice and deranged liver function in TB endemic regions along with early anticipation of liver transplant is necessary, as in this case.

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Budd-Chiari syndrome is an uncommon disease due to obstruction of hepatic venous outflow.

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Associated ascites and pleural effusion in a tuberculosis endemic condition can be confused with tuberculosis.

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Liver transplant can be ultimately required at later stage.

Normothermic Machine Perfusion as a Tool for Safe Transplantation of High-Risk Recipients

Normothermic machine perfusion (NMP) should no longer be considered a novel liver graft preservation strategy, but rather viewed as the standard of care for certain graft–recipient scenarios. The ability of NMP to improve the safe utilisation of liver grafts has been demonstrated in several publications, from numerous centres. This is partly mediated by its ability to limit the cold ischaemic time while also extending the total preservation period, facilitating the difficult logistics of a challenging transplant operation. Viability assessment of both the hepatocytes and cholangiocytes with NMP is much debated, with numerous different parameters and thresholds associated with a reduction in the incidence of primary non-function and biliary strictures. Maximising the utilisation of liver grafts is important as many patients require transplantation on an urgent basis, the waiting list is long, and significant morbidity and mortality is experienced by patients awaiting transplants. If applied in an appropriate manner, NMP has the ability to expand the pool of grafts available for even the sickest and most challenging of recipients. In addition, this is the group of patients that consume significant healthcare resources and, therefore, justify the additional expense of NMP. This review describes, with case examples, how NMP can be utilised to salvage suboptimal grafts, and our approach of transplanting them into high-risk recipients.

Budd-Chiari syndrome

Budd-Chiari syndrome (BCS) is a rare and potentially life-threatening disorder characterized by obstruction of the hepatic outflow tract at any level between the junction of the inferior vena cava with the right atrium and the small hepatic veins. In the West, BCS is a rare hepatic manifestation of one or more underlying prothrombotic risk factors. The most common underlying prothrombotic risk factor is a myeloproliferative disorder, although it is now recognized that almost half of patients have multiple underlying prothrombotic risk factors. Clinical manifestations can be diverse, making BCS a possible differential diagnosis of many acute and chronic liver diseases. The index of suspicion should be very low if there is a known underlying prothrombotic risk factor and new onset of liver disease. Doppler ultrasound is sufficient for confirming the diagnosis, although tomographic imaging (computed tomography (CT) or magnetic resonance imaging (MRI)) is often necessary for further treatment and discussion with a multidisciplinary team. Anticoagulation is the cornerstone of the treatment. Despite the use of anticoagulation, the majority of patients need additional (more invasive) treatment strategies. Algorithms consisting of local angioplasty, TIPS and liver transplantation have been proposed, with treatment choice dictated by a lack of response to a less-invasive treatment regimen. The application of these treatment strategies allows for a five-year survival rate of 90%. In the long term the disease course of BCS can sometimes be complicated by recurrence, progression of the underlying myeloproliferative disorder, or development of post-transplant lymphoma in transplant patients.

Mesoatrial shunt in Budd-Chiari syndrome

Background. Budd-Chiari syndrome (BCS) represents partial or total occlusion of the hepatic veins with or without simultaneous obstruction of vena cava inferior (VCI). The symptoms of BCS are abdominal pain, hepatomegaly, ascites, varices of the abdominal wall, sometimes bleeding from the upper part of gastointestinal tract (GIT), lower limbs swelling and jaundice. Primary BSC is a relatively rare condition occurring in one per 100 000 of the population worldwide. Case report. A male patient, 25-year-old, facing tooth postextraction complications, was presented with acute BCS. On admission, physical examination revealed pale-grayish complexion, more pronounced veins over the thorax and abdomen, ascites, enlarged liver rising 8 cm below the right costal arch and having a minor pleural effusion by the right side. The patient was submitted to Doppler sonography and computed tomography (CT) that verified the right leg deep veins thrombosis, as well as the presence of a thrombus in the intrahepatic portion of the VCI. Multislice computed tomography (MSCT) showed occlusion of hepatic veins (Budd-Chiari syndrome) and thrombosis of the VCI in the retrohepatic part 6 cm long. Also, increased values of transaminases and gamma GT and reduced values of albumines and serum ferrum were registered. Molecular examination revealed Factor V Leiden mutation - heterozygote. After preoperative preparations a mesocaval shunt was made using Gore- Tex ring graft of 12 mm. Intraoperatively, the blue enlarged liver was found with almost black zones of tense capsule. After a graft making, liver congestion decreased followed by the change of colour and volume. Within postoperative course metabolic and synthetic liver functions were obvious. Conclusion. In patients with BCS medicamentous treatment does not yield adequate results, but even causes worsening of general condition. Surgical therapy in the presented patient was performed timely regarding the stage of the disease due to which irreversible liver changes were prevented while decompression of the portal system provided time overbridging up to liver transplantation.