Management of Budd-Chiari syndrome

[Budd-Chiari syndrome, review and illustration]

Budd-Chiari syndrome is a rare vascular disorder characterized by obstruction of the hepatic venous outflow. Various diseases causing coagulopathy play a role in aetiology, such as myeloproliferative disorders. Acute vascular occlusion may lead to acute phlebitis with fever. The classic triad of acute liver failure may be present with ascites, hepatomegaly, and abdominal pain. However, subacute courses of disease were also observed. Because of the variable symptoms and severity extent, depending on the acuity of the course and the extent of the affected vessels, diagnosis is often difficult. Sonography, as a ubiquitously available and cost-effective diagnostic tool, plays a leading role. Doppler ultrasonography can be used to visualize hemodynamics in particular. In acute thrombotic occlusion, the affected hepatic veins usually cannot or only partially be visualized. In non-occluding thrombi, turbulent flow patterns may develop in the area of venous outflow obstruction, and flow velocity is then increased in the area of stenosis. Contrast enhanced ultrasound offers even better specificity of diagnosis. Computed tomography and magnetic resonance imaging can directly visualize thrombi and the cause of obstruction. Once the diagnosis is confirmed, anticoagulation must be initiated, but therapy of the underlying disease must also be started. If symptom-controlling measures are not sufficient, angioplasty/stenting to reopen short-segment stenoses or implantation of a TIPSS device may be considered. Liver transplantation remains ultima ratio. As studies on the precision of diagnostic methods are controversial, the characteristics of imaging for BCS are therefore summarized in this review on the basis of several illustrating case reports.

Abdominal and pelvic imaging findings associated with sex hormone abnormalities

Hormones are substances that serve as chemical communication between cells. They are unique biological molecules that affect multiple organ systems and play a key role in maintaining homoeostasis. In this role, they are usually produced from a single organ and have defined target organs. However, hormones can affect non-target organs as well. As such, biochemical and hormonal abnormalities can be associated with anatomic changes in multiple target as well as non-target organs. Hormone-related changes may take the form of an organ parenchymal abnormality, benign neoplasm, or even malignancy. Given the multifocal action of hormones, the observed imaging findings may be remote from the site of production, and may actually be multi-organ in nature. Anatomic findings related to hormone level abnormalities and/or laboratory biomarker changes may be identified with imaging. The purpose of this image-rich review is to sensitize radiologists to imaging findings in the abdomen and pelvis that may occur in the context of hormone abnormalities, focusing primarily on sex hormones and their influence on these organs.

Budd-Chiari syndrome: an update on imaging features

Budd-Chiari syndrome (BCS) is a rare cause of portal hypertension and liver failure. This condition is characterized by an impaired hepatic venous drainage. The diagnosis of BCS is based on imaging, which helps initiate treatment. Imaging findings can be categorized into direct and indirect signs. Direct signs are the hallmarks of BCS and consist of visualization of obstructive lesions of the hepatic veins or the upper portion of the inferior vena cava. Indirect signs, which are secondary to venous obstruction, correspond to intra- and extrahepatic collateral circulation, perfusion abnormalities, dysmorphy and signs of portal hypertension.

Ultrasound-guided transhepatic puncture of the hepatic veins for TIPS placement

PURPOSE

This retrospective analysis was carried out to assess the feasibility and results of transjugular intrahepatic portal systemic shunt (TIPS) performed with ultrasound (US)-guided percutaneous puncture of the hepatic veins.

MATERIAL AND METHODS

Over a period of 3 years, 153 patients were treated with TIPS at our centre. In eight cases, a percutaneous puncture of the middle (n=7) or right (n=1) hepatic vein was required because the hepatic vein ostium was not accessible. Indications for TIPS were bleeding (n=1), Budd-Chiari syndrome (n=1), ascites (n=2), reduced portal flow (n=1) and incomplete portal thrombosis (n=3). A 0.018-in. guidewire was anterogradely introduced into the hepatic vein to the inferior vena cava (IVC) through a 21-gauge needle. In the meantime, a 25-mm snare-loop catheter was introduced through the jugular access to retrieve the guidewire, achieving through-andthrough access. Then, a Rosch-Uchida set was used to place the TIPS with the traditional technique.

RESULTS

Technical success was achieved in all patients. There was one case of stent thrombosis. One patient died of pulmonary oedema. Three patients were eligible for liver transplantation, whereas the others were excluded due to shunt thrombosis (n=1) and previous nonhepatic neoplasms (n=3).

CONCLUSIONS

The percutaneous approach to hepatic veins is rapid and safe and may be useful for avoiding traumatic liver injuries.

A Novel Approach with Supra- and Retro-hepatic Cavocaval Bypass for Short Segmental Occlusion of Inferior Vena Cava in Budd-Chiari Syndrome

BACKGROUND

Budd-Chiari syndrome (BCS) is defined as chronic, progressive and congestive liver dysfunction resulting from obstruction of the outflow of inferior vena cava (IVC) and/or hepatic veins. One of the common types of BCS is short segmental occlusion of retrohepatic IVC (SSOR-IVC) accompanied by varied extent of obstruction of intrahepatic veins. The mainstay of surgical treatment at present for SSOR-IVC is cavoartrial bypass via thoracolaparotomic approach, in which thoracic and pulmonary complications intra- and/or post-operation are common. We have developed an abdominal approach using suprahepatic and retrohepatic inferior vena cavocaval bypass to treat SSOR-IVC, herein we compared it with the conventional thoracolaparotomic approach.

METHODS

From 2005 to 2008, we performed suprahepatic and retrohepatic inferior vena cavocaval bypass using artificial vessel in 16 BCS patients with SSOR-IVC (group A), we compared the results of this new modality with that using traditional thoracolaparotomic approach in 18 patients (group B) from 2001 to 2004.

RESULTS

In group A, one patient had intraoperative acute cardiac failure due to rapid opening of the bypassed vessel, and the symptom was resolved immediately through prompt management, while the others were not eventful during or post-operation. The length of artificial vessel required was 6 to 8 cm, and all patients had no graft vessel thrombosis after 10 to 55 months follow-up. In group B, one patient had intraoperative acute pericardial tamponment due to anastomotic leakage. The total occurrence rate of postoperative complication was 27.8%, including three pleural effusions, one pulmonary infection and one acute pericarditis. The length of the artificial vessel required was 12 to 14 cm. Three patients had graft vessel thrombosis at 37, 42 and 58 months post-operation, respectively.

CONCLUSIONS

The abdominal approach for suprahepatic and retrohepatic cavocaval bypass have advantages as follows over the traditional thoracolaparotomic approach for cavoartrial bypass: 1) Less traumatic with fewer postoperative thoracic and pulmonary complications; 2) A shorter artificial vessel required to facilitate endothelial seeding for improved long term patency; 3) Void of risk of fatal pericardial tamponment; 4) Prevention of acute pericarditis due to pericardial irritation by the artificial vessel in the thoracolaparotomic approach. We concluded that this novel abdominal approach is a safe and effective technique for treatment of SSOR-IVC.

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.

Liver transplantation with reconstruction of the inferior vena cava for hepatocarcinoma on chronic Budd-Chiari: a case report

Management of Budd-Chiari syndrome, from simple medical treatment to liver transplantation, depends on the acute and chronic evolution of the disease and on the degree of hepatic insufficiency. Herein we have reported the case of a man who underwent transplantation after evolution of a Budd-Chiari syndrome with membranous obstruction of the vena cava and developed 2 lesions of hepatocellular carcinoma. Surgery was difficult due to previous procedures requiring reconstruction of the supra-hepatic vena cava. This case emphasized the timing of liver transplantation versus other treatments to decrease the operative risk.

Long-term outcome of a covered vs. uncovered transjugular intrahepatic portosystemic shunt in Budd-Chiari syndrome

BACKGROUND

The clinical outcome of a covered vs. uncovered transjugular intrahepatic portosystemic shunt (TIPS) for patients with Budd-Chiari syndrome (BCS) is as yet largely unknown.

OBJECTIVES

To compare patency rates of bare and polytetrafluoroethylene (PTFE)-covered stents, and to investigate clinical outcome using four prognostic indices [Child-Pugh score, Rotterdam BCS index, modified Clichy score and Model for End-Stage Liver Disease (MELD)].

METHODS

Consecutive patients with BCS who had undergone TIPS between January 1994 and March 2006 were evaluated in a retrospective review in a single centre.

RESULTS

Twenty-three TIPS procedures were performed on 16 patients. The primary patency rate at 2 years was 12% using bare and 56% using covered stents (P=0.09). We found marked clinical improvement at 3 months post-TIPS as determined by a drop in median Child-Pugh score (10-7, P=0.04), Rotterdam BCS index (1.90-0.83, P=0.02) and modified Clichy score (7.77-2.94, P=0.003), but not in MELD (18.91-17.42, P=0.9). Survival at 1 and 3 years post-TIPS was 80% (95% CI: 59-100%) and 72% (95% CI: 48-96%). Four patients (25%) died and one required liver transplantation.

CONCLUSIONS

A transjugular intrahepatic portosystemic shunt using PTFE-covered stents shows better patency rates than bare stents in BCS. Moreover, TIPS leads to an improvement in important prognostic indicators for the survival of patients with BCS.

Interventional radiology in the management of Budd Chiari syndrome

Budd Chiari syndrome is an uncommon condition in the Western world but interventional radiology can contribute significantly to the management of the majority of patients. This review examines the role and technique of interventions including hepatic vein dilatation and stent insertion as well as thrombolysis and TIPS. Liver transplantation and surgical shunt surgery are discussed in relation to radiological interventions. With appropriate selection and technique, surgery is only required in a minority of patients.

Budd-Chiari syndrome from an advanced practice nurse perspective

PURPOSE

To provide nurse practitioners (NPs) with a case study and literature review of Budd-Chiari syndrome (BCS). This rare liver disease has a multitude of clinical presentations that NPs may encounter in the primary care setting.

DATA SOURCE

A literature search was conducted in Pub-Med and CINAHL using key search words. Information for the case study was obtained from a patient and his gastroenterology specialist, who is a foremost expert in this field.

CONCLUSION

BCS is complex and may be difficult to diagnose because of its atypical clinical presentation. Delayed diagnosis can affect the quality and quantity of a patient's life. Increasing NPs' awareness about this rare condition through a case presentation and review of the literature emphasizes the major factors for accurate diagnosis.

IMPLICATIONS FOR PRACTICE

Knowledge of BCS can assist the NP in identifying this syndrome and making prompt, appropriate referrals.

Budd-Chiari syndrome: spectrum of imaging findings

OBJECTIVE

The objective of our study was to illustrate the imaging findings of Budd-Chiari syndrome, including CT, MRI, sonographic, and angiographic findings.

CONCLUSION

The key imaging findings in Budd-Chiari syndrome are occlusion of the hepatic veins, inferior vena cava, or both; caudate lobe enlargement; inhomogeneous liver enhancement; and the presence of intrahepatic collateral vessels and hypervascular nodules. Awareness of these findings is important for early diagnosis and appropriate treatment.

Budd-Chiari syndrome

Budd-Chiari syndrome is a spectrum of disease states, including anatomic abnormalities and hypercoagulable disorders, resulting in hepatic venous outflow occlusion. Clinical manifestations observed in the majority of patients include hepatomegaly, right upper quadrant pain, and abdominal ascites. This article outlines the approach to clinical diagnosis and supportive medical therapy in patients who have BCS and reviews the clinical data supporting surgical shunting and liver transplantation as viable treatment options in this patient population.

Primary Budd-Chiari syndrome: outcome of endovascular management for suprahepatic venous obstruction

OBJECTIVE

Primary Budd-Chiari syndrome (BCS) is a rare form of hepatic venous outflow obstruction at the suprahepatic inferior vena cava (IVC), the hepatic veins, or both. We assessed our 4-year experience in the management of BCS to evaluate the results of our methods of care.

METHODS

We conducted a retrospective review of a nonrandomized clinical trial conducted in three teaching hospitals. Among 28 primary BCS patients, 9 remained in medical treatment only, and 19 who failed to respond to medical treatment received additional endovascular (n = 17) or surgical therapy (n = 2). Nine underwent IVC balloon angioplasty alone, 6 had angioplasty plus stents, and 2 had transjugular intrahepatic portosystemic shunts (TIPS) for hepatic vein lesions. One patient had a mesoatrial bypass; another had liver transplantation. Immediate response to the therapy was assessed with angiography and ultrasonography based on anatomic and/or hemodynamic correction or reduction of the lesion. Subsequent assessment of portal hypertension status was made with periodic clinical and laboratory evaluation (eg, ultrasonography, liver biopsy).

RESULTS

Twenty-six patients had had IVC stenosis or occlusion by focal or segmental lesion. Two patients had hepatic vein outlet obstruction. There was no evidence of coagulopathy as the pathogenesis; all were related to membranous obstruction of the vena cava. Excellent immediate response to the endovascular therapy and subsequent relief of portal hypertension were achieved in 14 patients. Four patients had restenosis or progression of the residual lesion within 2 years; three responded to repeated stenting. Primary patency was 76.5%, and primary assisted patency was 94.1%. Two patients with TIPS and two with surgical therapy maintained excellent results. The medical treatment remained effective only in a limited group of 6 (21.4%) of the 28 patients.

CONCLUSIONS

In BCS, both endovascular and surgical interventions provide excellent results and potentially halt liver parenchymal deterioration caused by portal hypertension. Liver transplantation remains the ultimate solution for advanced liver failure.