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Husieva SA, Osyodlo GV, Husiev AV, Savichan KV. A Clinical Case of Timely Diagnosis and Successful Treatment of Budd-Chiari Syndrome With Fulminant Cytolysis in the Setting of a First-time Diagnosed Myeloproliferative Disease. Mil Med 2024:usae331. [PMID: 38935394 DOI: 10.1093/milmed/usae331] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/14/2024] [Revised: 05/03/2024] [Accepted: 06/23/2024] [Indexed: 06/28/2024] Open
Abstract
The article presents a clinical case of peculiarities of clinical manifestations, diagnostic and therapeutic approaches of undiagnosed chronic myeloproliferative disease, on the background of which Budd-Chiari syndrome (BCS) developed. The results of clinical course, examination, and treatment of a patient with BCS as a manifestation of the hidden course of primary myelofibrosis with the presence of somatic mutation (V617F) in Janus-tyrosine kinase-2 (JAK2) gene in myeloid cells are presented. Standard clinical and laboratory examinations, and cytomorphologic and histologic examination of bone marrow were used. The diagnosis of BCS was confirmed by ultrasound (US) Doppler examination of the portal system vessels. Symptomatic therapy resulted in insignificant positive results. The analysis of this clinical case showed that the development of BCS was due to a chronic myeloproliferative disease that was not diagnosed before the development of thrombosis. Hepatic vein thrombosis was accompanied by the development of fulminant cytolytic syndrome. Along with symptomatic therapy, patient K., female, 32 years old, underwent transjugular intrahepatic portosystemic shunting 1 month after the first symptoms of BCS appeared, which contributed to a significant clinical effect. Seven years after the installation of 4 transjugular intrahepatic portosystemic shunts, the patient's condition remains satisfactory. The uniqueness of this clinical case lies in the presence of 2 serious diseases at the same time: myeloproliferative pathology (primary myelofibrosis) JAK2-positive variant and BCS. Timely diagnosis of both hematological diseases and their complication in the form of hepatic vein thrombosis with fulminant cytolytic syndrome allowed timely prescription of adequate treatment with a good clinical response.
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Affiliation(s)
- Svitlana A Husieva
- Military Therapy Department, Ukrainian Military Medical Academy, Kyiv 01015, Ukraine
| | - Galyna V Osyodlo
- Military Therapy Department, Ukrainian Military Medical Academy, Kyiv 01015, Ukraine
| | - Andrii V Husiev
- Department of Liver Surgery and Transplantation, Shalimov National Scientific Center of Surgery and Transplantation of the National Academy of Medical Sciences of Ukraine, Kyiv 03680, Ukraine
| | - Kyrylo V Savichan
- Military Therapy Department, Ukrainian Military Medical Academy, Kyiv 01015, Ukraine
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Rahayatri TH, Ruslie J, Kasahara M. Living donor liver transplantation on pediatric patient with Budd-Chiari syndrome: Case report and literature review. Int J Surg Case Rep 2024; 115:109294. [PMID: 38290357 PMCID: PMC10840357 DOI: 10.1016/j.ijscr.2024.109294] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/20/2023] [Revised: 01/17/2024] [Accepted: 01/18/2024] [Indexed: 02/01/2024] Open
Abstract
INTRODUCTION The management of Budd-Chiari syndrome is determined on the basis of the severity of the disease. There are no standard guidelines regarding the management of Budd-Chiari syndrome in children, particularly in cases of liver transplantation. Therefore, we present a case of a pediatric patient with Budd-Chiari syndrome treated with liver transplantation. CASE PRESENTATION A female patient aged 1 year and 8 months presented to the hospital with an enlarged stomach in the last 1.5 months before admission. The patient was moderately ill, malnourished, and jaundiced. Liver biopsy revealed fibrosis in the portal area and confluent necrosis caused by vascular disorders. Magnetic resonance imaging (MRI) revealed a nutmeg liver and ascites due to the stenosis of the inferior vena cava at the level of the liver and the middle and left hepatic veins. The patient underwent living-donor liver transplantation. The occlusion of the proximal right hepatic vein due to the presence of a membrane was identified as the cause of Budd-Chiari syndrome in this case. Postoperatively, the patient's condition was stable and there was no sepsis or any other complications. CLINICAL DISCUSSION Prothrombotic factors are often the underlying cause of more than 80 % of Budd-Chiari syndrome cases. Protein C deficiency is suspected to be a prothrombotic factor that triggers Budd-Chiari syndrome in patients. Liver transplantation is the treatment of choice for patients with Budd-Chiari syndrome who were not treated with anticoagulation therapy, angioplasty, and TIPS. CONCLUSION Living-donor liver transplantation has a good outcome in the management of pediatric patients with Budd-Chiari syndrome.
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Affiliation(s)
- Tri Hening Rahayatri
- Faculty of Medicine, Universitas Indonesia, Department of Pediatric Surgery, Cipto Mangunkusumo Hospital, Jakarta, Indonesia.
| | - Jason Ruslie
- Faculty of Medicine, Universitas Indonesia, Department of Surgery, Cipto Mangunkusumo Hospital, Jakarta, Indonesia
| | - Mureo Kasahara
- Department of Transplantation, National Center for Child Health and Development, Tokyo, Japan
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Cohen O, Efros O, Riva N, Ageno W, Soffer S, Klang E, Barg AA, Kenet G, Levy-Mendelovich S. Anticoagulant treatment for pediatric splanchnic vein thrombosis: a systematic review and meta-analysis. J Thromb Haemost 2023; 21:2499-2508. [PMID: 37225019 DOI: 10.1016/j.jtha.2023.05.014] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/18/2023] [Revised: 04/29/2023] [Accepted: 05/10/2023] [Indexed: 05/26/2023]
Abstract
BACKGROUND The clinical characteristics of splanchnic vein thrombosis (SVT) in pediatric patients and its optimal treatment strategies are unknown. OBJECTIVES This study aimed to assess the effectiveness and safety of anticoagulant therapy for pediatric SVT. METHODS MEDLINE and EMBASE databases were searched up to December 2021. We included observational and interventional studies that enrolled pediatric patients with SVT and reported anticoagulant treatment and outcomes, including rates of vessel recanalization, SVT extension, venous thromboembolism (VTE) recurrence, major bleeding, and mortality. Pooled proportions of vessel recanalization were calculated with their 95% CI. RESULTS A total of 506 pediatric patients (aged 0-18 years) across 17 observational studies were included. The majority of patients had portal vein thrombosis (n = 308, 60.8%) or Budd-Chiari syndrome (n = 175, 34.6%). Most events were triggered by transient provoking factors. Anticoagulation (heparins and vitamin K antagonists) was prescribed in 217 (42.9%) patients, and 148 (29.2%) patients underwent vascular interventions. The overall pooled proportions of vessel recanalization were 55.3% (95% CI, 34.1%-74.7%; I2 = 74.0%) among anticoagulated patients and 29.4% (95% CI, 2.6%-86.6%; I2 = 49.0%) among non-anticoagulated patients. SVT extension, major bleeding, VTE recurrence, and mortality rates were 8.9%, 3.8%, 3.5%, and 10.0%, respectively, in anticoagulated patients and 2.8%, 1.4%, 0%, and 50.3%, respectively, in non-anticoagulated patients. CONCLUSION In pediatric SVT, anticoagulation appears to be associated with moderate recanalization rates and a low risk of major bleeding. VTE recurrence is low and comparable to that reported in pediatric patients with other types of provoked VTE.
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Affiliation(s)
- Omri Cohen
- National Hemophilia Center, Institute of Thrombosis and Hemostasis, Sheba Medical Center, Tel-Hashomer, Israel; Sackler School of Medicine, Tel Aviv University, Tel Aviv, Israel; Department of Medicine and Surgery, University of Insubria, Varese, Italy
| | - Orly Efros
- National Hemophilia Center, Institute of Thrombosis and Hemostasis, Sheba Medical Center, Tel-Hashomer, Israel; Sackler School of Medicine, Tel Aviv University, Tel Aviv, Israel
| | - Nicoletta Riva
- Department of Pathology, Faculty of Medicine and Surgery, University of Malta, Msida, Malta
| | - Walter Ageno
- Department of Medicine and Surgery, University of Insubria, Varese, Italy
| | - Shelly Soffer
- Internal Medicine B, Assuta Medical Center, Ashdod, Israel; Ben-Gurion University of the Negev, Be'er Sheva, Israel
| | - Eyal Klang
- Sackler School of Medicine, Tel Aviv University, Tel Aviv, Israel; Department of Diagnostic Imaging, Sheba Medical Center, Tel-Hashomer, Israel; Sheba Talpiot Medical Leadership Program, Sheba Medical Center, Tel-Hashomer, Israel
| | - Assaf A Barg
- National Hemophilia Center, Institute of Thrombosis and Hemostasis, Sheba Medical Center, Tel-Hashomer, Israel; Sackler School of Medicine, Tel Aviv University, Tel Aviv, Israel
| | - Gili Kenet
- National Hemophilia Center, Institute of Thrombosis and Hemostasis, Sheba Medical Center, Tel-Hashomer, Israel; Sackler School of Medicine, Tel Aviv University, Tel Aviv, Israel
| | - Sarina Levy-Mendelovich
- National Hemophilia Center, Institute of Thrombosis and Hemostasis, Sheba Medical Center, Tel-Hashomer, Israel; Sackler School of Medicine, Tel Aviv University, Tel Aviv, Israel; Sheba Talpiot Medical Leadership Program, Sheba Medical Center, Tel-Hashomer, Israel.
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Redkar R, Raj V, Tewari S, Sharma R, Joshi S. Balloon venoplasty as primary modality of treatment in children with Budd-Chiari syndrome. J Pediatr Surg 2020; 55:2183-2186. [PMID: 32553452 DOI: 10.1016/j.jpedsurg.2020.05.021] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 09/16/2019] [Revised: 05/11/2020] [Accepted: 05/13/2020] [Indexed: 11/30/2022]
Abstract
INTRODUCTION Budd-Chiari syndrome (BCS) is a rare condition affecting children. It is characterized by occlusion of venous outflow from liver at the level of hepatic veins (HV) or inferior vena cava (IVC). The management of BCS in children revolves around forming new collaterals for venous outflow or by elimination of blockage in the venous outflow tracts. These can be achieved by balloon venoplasty (BV), transjugular intrahepatic portosystemic shunting (TIPSS) or open shunt surgeries. AIM The aim of this study is to evaluate the management of BCS in children with balloon venoplasty as primary modality of treatment. MATERIALS AND METHODS This is a retrospective study which includes children diagnosed with BCS managed by balloon venoplasty by a single surgeon at a single institute. Once confirmed, the child was posted for balloon venoplasty and liver biopsy. When venoplasty was successful, child was subsequently heparinized and dose titrated. Routine follow up was mandated and dose adjustments were continued during follow up. In case of unsuccessful venoplasty, depending on the liver biopsy report, shunt procedure or liver transplantation is offered to patients. An algorithm was then designed for management of BCS in children. RESULTS A total of 35 children who underwent evaluation of symptoms associated with Budd-Chiari syndrome were included in the study. Of all the children, 14 are alive and symptom free, 9 are deceased and 12 lost to follow up. Hepatic vein was the most common site of obstruction (85%), followed by both IVC and HV (15%). Overall, in 35 children, 26 had a successful balloon venoplasty, in 3 venoplasty was not done (2 spontaneous resolution and 1 died awaiting), in 6 it was unsuccessful (3 technical failures: 1 underwent TIPSS and 2 lost to follow up, 3 clinical failures: portocaval shunt for failed venoplasty). CONCLUSION Budd-Chiari syndrome is a rare condition affecting children. Balloon venoplasty as a primary modality of treatment for BCS is a promising option for management in children. Early and aggressive use of radiological intervention can help achieve recanalization in children. TYPE OF STUDY Clinical research paper. LEVEL OF EVIDENCE Level IV.
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Affiliation(s)
- Rajeev Redkar
- Consultant Pediatric Surgeon, Lilavati Hospital & Research Centre, Mumbai.
| | - Vinod Raj
- Department of Pediatric Surgery, Lilavati Hospital & Research Centre, Mumbai
| | - Shruti Tewari
- Department of Pediatric Surgery, Lilavati Hospital & Research Centre, Mumbai
| | - Rahul Sharma
- Department of Pediatric Surgery, Lilavati Hospital & Research Centre, Mumbai
| | - Shirin Joshi
- Department of Pediatric Surgery, Lilavati Hospital & Research Centre, Mumbai
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Budd-Chiari syndrome in children: clinical features, percutaneous radiological intervention, and outcome. Eur J Gastroenterol Hepatol 2014; 26:1030-8. [PMID: 25003745 DOI: 10.1097/meg.0000000000000144] [Citation(s) in RCA: 45] [Impact Index Per Article: 4.5] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 01/27/2023]
Abstract
OBJECTIVES 'Radiological intervention' to restore venous patency is the preferred therapy in adults with Budd-Chiari syndrome (BCS). The published literature on pediatric BCS is scarce. This study evaluated the clinical profile and role of a therapeutic radiological intervention in children with BCS. PATIENTS AND METHODS Forty-six BCS children [29 boys, median age 10.5 (2-16) years] were enrolled. Standard medical therapy was administered to all. A radiological intervention, angioplasty [hepatic vein (HV) (n=3)], stenting [HV (n=18), inferior vena cava (IVC) (n=5)], transjugular intrahepatic portosystemic shunt (TIPS) (n=3), was performed in 25 cases. Clinical, biochemical, and radiological follow-up was carried out. RESULTS Doppler ultrasonography was diagnostic in 95% of cases. All patients had chronic BCS, with ascites in 82.6%, hepatomegaly in 84.8%, splenomegaly in 69.6%, prominent abdominal veins in 69.6%, and variceal bleed in 34.8% cases. The most common site of block was HV (n=33), followed by combined HV and IVC block (n=11), and isolated IVC block (n=2). Eight of 12 (75%) cases had abnormal procoagulant workup. Radiological intervention was technically successful in 100%. Clinical and biochemical improvement was observed in the intervention group. Complications included neck hematoma and hemorrhagic ascites in one patient each. One child in the intervention group (post-TIPS sudden cardiac event) and two children in the nonintervention group [end-stage liver disease (n=1), head injury (n=1)] died. Stent was patent in 15/20 (75%) children over a median follow-up of 6.5 months. CONCLUSION HV block and a chronic presentation are most common in BCS children. Doppler ultrasonography establishes the diagnosis in 95% of cases. Radiological intervention is an effective and safe therapeutic modality for children with BCS.
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Squires RH, Ng V, Romero R, Ekong U, Hardikar W, Emre S, Mazariegos GV. Evaluation of the pediatric patient for liver transplantation: 2014 practice guideline by the American Association for the Study of Liver Diseases, American Society of Transplantation and the North American Society for Pediatric Gastroenterology, Hepatology and Nutrition. Hepatology 2014; 60:362-98. [PMID: 24782219 DOI: 10.1002/hep.27191] [Citation(s) in RCA: 134] [Impact Index Per Article: 13.4] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 04/22/2014] [Accepted: 04/22/2014] [Indexed: 12/16/2022]
Affiliation(s)
- Robert H Squires
- Department of Pediatrics, University of Pittsburgh School of Medicine; Division of Pediatric Gastroenterology, Hepatology and Nutrition, Children's Hospital of Pittsburgh of UPMC, Pittsburgh, PA
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Gomes AC, Rubino G, Pinto C, Cipriano A, Furtado E, Gonçalves I. Budd-Chiari syndrome in children and outcome after liver transplant. Pediatr Transplant 2012; 16:E338-41. [PMID: 22452639 DOI: 10.1111/j.1399-3046.2012.01683.x] [Citation(s) in RCA: 5] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/28/2022]
Abstract
BCS is a rare form of portal hypertension in children. The authors describe two cases of BCS with differing presentations. Case 1: Previously healthy four-yr-old girl. BCS was diagnosed during the course of an episode of acute gastroenteritis with dehydration. Despite conservative therapy for two months, the condition was progressive resulting in liver failure leading ultimately to LT. Molecular studies showed that she was heterozygous for the Factor (F) V Leiden. At follow-up, six yr post-LT (two yr without anticoagulation therapy), no thromboembolic/bleeding events were apparent. Case 2: Three-yr-old boy with IgA deficiency and liver disease. Following a febrile episode, he developed fulminant liver failure requiring urgent LT from a living donor (father). Molecular studies disclosed MTHFR C677T homozygosity and FV Leiden heterozygosity. The father was homozygous for the MTHFR mutation. Three months post-LT, persistent graft dysfunction was associated with stenosis of the IVC, which improved upon stent placement. He received dipyridamole and aspirin for five yr, after which time dipyridamole was discontinued. Evidence is sparse on the follow-up of BCS cases with liver transplant. The authors discuss their findings, particularly the need for long-term anticoagulation.
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Affiliation(s)
- Ana Cristina Gomes
- Hospital Pediátrico de Coimbra, Centro Hospitalar da Universidade de Coimbra, Coimbra, Portugal.
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Hepatic venous outflow obstruction complicating Churg-Strauss syndrome in a 5-year-old child. J Pediatr Gastroenterol Nutr 2011; 52:217-8. [PMID: 21240017 DOI: 10.1097/mpg.0b013e3181f507d7] [Citation(s) in RCA: 8] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 01/05/2023]
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Hasija RP, Nagral A, Marar S, Bavdekar AR. Transjugular intrahepatic portosystemic shunt (TIPSS) for Budd Chiari syndrome. Indian Pediatr 2010; 47:527-8. [DOI: 10.1007/s13312-010-0081-7] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/28/2022]
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Paediatric chronic liver diseases: how to investigate and follow up? Role of imaging in the diagnosis of fibrosis. Pediatr Radiol 2010; 40:906-19. [PMID: 20432008 DOI: 10.1007/s00247-010-1600-3] [Citation(s) in RCA: 40] [Impact Index Per Article: 2.9] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 01/25/2010] [Accepted: 01/28/2010] [Indexed: 12/23/2022]
Abstract
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.
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Abstract
OBJECTIVES Budd-Chiari syndrome (BCS) in children is not uncommon. Published literature on therapy for this condition is scarce. We therefore attempted radiological interventions in these patients to determine their efficacy and safety. PATIENTS AND METHODS Fourteen of 16 children with a median age of 22 months diagnosed as having BCS were subjected to an inferior vena cava/hepatic venogram with the aim to establish a normal antegrade flow in at least 1 hepatic vein (HV). RESULTS A normal antegrade flow in at least 1 of the HVs could be established in 11 children. Three patients had angioplasty of the HV (vein size <or=4 mm), 2 underwent HV stent placements (vein size >or=5 mm), and 6 had transjugular intrahepatic porta systemic shunt ([TIPSS] total occlusion of all 3 HVs or veno-occlusive disease). The youngest child undergoing a successful stenting was 7 months of age and the child undergoing TIPSS was 3 years of age. One patient had reversal of fulminant liver failure following a successful TIPSS. Postprocedure, 2 patients developed reversible encephalopathy and 1 had a neck hematoma. There was no procedure-related mortality. The procedure was successful in both patients with stenting (100%), 5 of the 6 patients with TIPSS (80%), and only 1 of the 4 patients (25%) with angioplasty. The median follow-up was 31 months. CONCLUSIONS Radiological therapeutic intervention is feasible and safe in children with BCS. The overall results of stenting/TIPSS are better than with angioplasty; however, long-term results of these interventions need to be evaluated.
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Carnevale FC, Santos ACB, Tannuri U, Cerri GG. Hepatic Veins and Inferior Vena Cava Thrombosis in a Child Treated by Transjugular Intrahepatic Portosystemic Shunt. Cardiovasc Intervent Radiol 2009; 33:627-30. [DOI: 10.1007/s00270-009-9647-y] [Citation(s) in RCA: 5] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 04/06/2009] [Revised: 06/11/2009] [Accepted: 06/23/2009] [Indexed: 10/20/2022]
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Cakir M, Ozgenc F, Baran M, Arikan C, Sezak M, Tuncyurek M, Ergun O, Yagci RV. A rare cause of refractory ascites in a child: familial Mediterranean fever. Rheumatol Int 2009; 30:531-4. [DOI: 10.1007/s00296-009-0957-9] [Citation(s) in RCA: 7] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/22/2008] [Accepted: 05/03/2009] [Indexed: 11/28/2022]
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