Case report: unusual CT appearances in a case of Budd-Chiari syndrome

Hepatic Necrosis Mimicking Infiltrative Masses in Acute Budd-Chiari Syndrome With Hereditary Protein C Deficiency

We report the case of a patient with an unusual acute Budd-Chiari syndrome (BCS). The patient presented with high-grade fever and right upper quadrant pain. Infiltrative lesions at the right hepatic lobe and segment IVB with intrahepatic inferior vena cava and right hepatic vein thrombus appeared on abdominal imaging. Liver biopsy revealed hepatic infarction compatible with acute BCS. Thrombophilia work-up demonstrated low protein C activity with the -1657C/T mutation of the PROC gene. Necrotic liver mass with acute BCS related to congenital protein C deficiency was diagnosed. Patient symptoms and necrotic masses improved after anticoagulant treatment for 4 months.

Pseudotumours of hepatic imaging

The diagnosis of liver tumours with CT depends on differential attenuation coefficients and enhancement patterns. The sensitivity of CT in defining tumours is well established but there remain a variety of conditions that mimic these patterns, presenting a 'pseudotumour' appearance. A common illustrative example is hepatic steatosis, but less well recorded are the sphingolipidoses and intrahepatic arterioportal shunts, either post-traumatic or related to venous outflow block. Alpha-1-antitrypsin deficiency and hereditary tyrosinaemia provide examples in childhood.

Budd-Chiari syndrome

Budd-Chiari syndrome is the generic term for different forms of hepatic venous outflow obstruction resulting in a clinical picture of portal hypertension and hepatomegaly. Three levels of venous outflow obstruction may be recognized, affecting respectively the small intrahepatic (IVC). Each level of obstruction is related to a different aetiology. Clinical manifestations range from mild symptoms to acute or chronic end-stage liver disease. Treatment is surgical in the great majority of patients. Occlusion of the IVC may be treated by removal of the caval obstruction in selected patients. Hepatic outflow obstruction may be circumvented by different forms of shunting from the portal or upper mesenteric vein to the IVC or right atrium, depending on the level of obstruction and the difference in venous pressure. For the rare patient presenting with acute or chronic end-stage liver failure, hepatic transplantation may be a life-saving procedure.

Hepatic mass in Budd-Chiari syndrome: CT and MRI findings

We describe a case of Budd-Chiari syndrome, secondary to a hypercoagulable state, which produced a mass lesion on computerized tomography (CT) and magnetic resonance imaging (MRI) examinations. The mass simulated a tumor, but proved to be an area of hemorrhagic necrosis upon biopsy. The finding of a space occupying lesion may not always indicate a tumor in a patient with the Budd-Chiari syndrome. The causes, pathologic changes, and radiologic findings of Budd-Chiari syndrome are discussed.