Primary Budd-Chiari Syndrome

Basics of diagnosis and treatment of venous thromboembolism

Venous thromboembolism (VTE), comprising deep vein thrombosis and pulmonary embolism (PE), is common and associated with significant morbidity and mortality. The symptoms and signs of VTE are nonspecific. Well-established integrated diagnostic strategies combining clinical probability scores and D-dimer are used to identify patients with a low probability of VTE, where the diagnosis can be safely excluded without imaging. In patients with confirmed VTE, anticoagulation is the mainstay of treatment. However, patients with high-risk features at presentation may benefit from advanced reperfusion therapies such as thrombolysis and/or interventional approaches to reduce early mortality and/or long-term morbidity. The advent of direct oral anticoagulants has greatly simplified the treatment of VTE for most patients, with a persisting role for low molecular weight heparin and vitamin K antagonists in select patient groups. Following an initial 3 to 6 months of anticoagulation, those with major transient provoking factors can safely discontinue anticoagulation. Balancing the risk of recurrent VTE and bleeding risk is central to decisions regarding long-term anticoagulation, and patients should be included in shared decision-making. Assessment and recognition of common long-term complications such as postthrombotic syndrome and post-PE syndrome are also essential, given they are associated with significant adverse impact on long-term quality of life, with a significant risk of mortality associated with the less frequent complication of chronic thromboembolic pulmonary hypertension. This review provides a basic overview and framework for the diagnostic approach to deep vein thrombosis and PE, risk stratification of confirmed diagnoses, and management.

Budd Chiari syndrome associated with antiphospholipid syndrome: Clinical characteristics and prognosis of 17 patients from single center

Background and AimIn this retrospective, descriptive study, we aimed to identify clinical and laboratory characteristics, and prognoses of patients with Budd-Chiari syndrome (BCS) secondary to antiphospholipid syndrome (APS) and to compare with non-BCS vascular thrombotic APS patients.MethodsData of 194 patients with thrombotic APS (17 with BCS) ± systemic lupus erythematosus (SLE) in a single center between 1982 and 2023 were evaluated. Antiphospholipid serology consisting of lupus anticoagulant (LA), anticardiolipin (aCL) IgG/IgM, anti-beta2 glycoprotein I (aβ2GPI) IgG/IgM and adjusted global APS score (aGAPSS) were evaluated to determine thrombotic risk. Damage was identified for all patients by applying the damage index for APS (DIAPS). All patients with BCS were screened for hereditary or acquired prothrombotic disorders.ResultsPatients with BCS had higher aGAPSS and recurrent thrombosis (70.6% vs 40.7%) compared to those with non-BCS. BCS was the first thrombotic event in eight patients and three had recurrent thrombosis. The most common presenting manifestation of BCS was abdominal pain which was followed by abdominal distention and fever. The second prothrombotic factor was detected in six patients: three had heterozygous factor V Leiden mutation, three were in pregnancy period. Additionaly, two patients had SLE flare. The DIAPS of the patients in the BCS and non-BCS groups were similar, but those in the BCS group had higher mortality rates.ConclusionsAPS patients with BCS may have a higher risk of recurrent thrombosis and mortality. Acquired or hereditary prothrombotic disorders are not uncommon in this group and should be screened in APS patients with BCS.

Clinical characteristics and risk factors of hepatocellular carcinoma development in Budd-Chiari syndrome patients after endovascular treatment

BACKGROUND AND AIMS

Endovascular treatment has improved Budd-Chiari syndrome (BCS) patient outcomes, but patients remain at risk for developing hepatocellular carcinoma (HCC). We aimed to analyse the characteristics and risk factors for HCC development in BCS patients after endovascular treatment.

METHODS

Clinical data of BCS patients who had received endovascular treatment were retrospectively reviewed. Characteristics of BCS patients who developed HCC post-treatment were compared with those without HCC development. Univariable and multivariable Cox regression analyses were used to determine the risk factors.

RESULTS

We enrolled 302 BCS patients. HCC was confirmed in 31 patients after treatment. Early-stage tumours were the most common (11/31, 35.5 %) according to the Barcelona Clinic Liver Cancer staging system. A serum alpha fetoprotein (AFP) cut-off level of > 15.7 ng/mL showed a sensitivity of 69.3 % and specificity of 97.4 % for detecting HCC in these patients. The presence of preoperative liver cirrhosis (hazard ratio (HR)=4.677; P = 0.043) and postoperative restenosis (HR=6.867; P < 0.001) were independent risk factors associated with HCC development in BCS patients after endovascular treatment.

CONCLUSION

HCCs that develop after endovascular treatment in BCS patients are often detected at an early stage. Preoperative liver cirrhosis and postoperative restenosis were independent risk factors for HCC development in these individuals.

Mechanisms and aetiology-dependent treatment of acute liver failure

This review compiles the mechanisms of acute liver failure (ALF) as well as the current and potential therapeutic approaches, including aetiology-specific treatment, and the issues encountered with such approaches. On a cellular level, ALF is characterized by massive hepatocyte death due to different types of cellular demise. Compensatory hyperplasia and functional recovery are possible when the regenerative capacity is sufficient to sustain hepatic function. ALF has a high mortality of about 30% and can lead to death in a very short time despite maximum therapeutic intervention. Besides aetiology-specific therapy and intensive care, the therapeutic option of emergency liver transplantation has significantly improved the prognosis of patients with ALF. However, due to limiting factors such as organ shortage, many patients die on the waiting list. In addition to graft assessment, machine perfusion may have the potential to recondition marginal organs and thus expand the organ donor pool.

A rare pediatric case: Budd-Chiari Syndrome and upper gastrointestinal bleeding in a 5-year-old boy

INTRODUCTION AND IMPORTANCE

Budd-Chiari Syndrome (BCS) is a rare condition characterized by hepatic venous outflow obstruction, often presenting with ascites, hepatomegaly, and abdominal pain. The diagnosis and management of BCS, especially in resource-limited settings, pose significant challenges that can lead to poor patient outcomes.

CASE PRESENTATION

This case report describes a previously healthy individual presenting with progressive abdominal distention, hematemesis, and right upper quadrant pain. The patient had a history of trauma and underwent subsequent percutaneous drainage for ascites. Imaging studies revealed non-opacified hepatic veins, splenomegaly, ascites, and a "nutmeg liver" pattern, confirming the diagnosis of BCS. The patient received blood transfusions, diuretics, and nutritional support. A Transjugular Intrahepatic Portosystemic Shunt (TIPS) procedure was planned but ultimately hindered by financial constraints.

CLINICAL DISCUSSION

This case highlights the challenges of managing BCS in resource-limited settings, particularly regarding access to specialized treatments like TIPS. It emphasizes the need for early diagnosis, multidisciplinary care, and the development of cost-effective treatment strategies to improve patient outcomes.

CONCLUSION

The management of Budd-Chiari Syndrome is complex, particularly in settings with limited resources. This case underscores the importance of timely intervention and the need for innovative approaches to healthcare delivery that can accommodate financial barriers while ensuring patient safety and care quality.

Splanchnic vein thrombosis: management for the thrombosis specialist

Splanchnic vein thrombosis (SpVT) is an uncommon site of venous thrombosis that is associated with complications including portal hypertension and hepatic dysfunction. The evaluation and management of this patient population has evolved in recent years, but there are limited data from clinical trials to guide management. Given the various acquired and biologic risk factors leading to the development of SpVT and the potential complications that can arise from it, input from a multidisciplinary team can be valuable in managing such patients, including thrombosis specialists or hematologists, gastroenterologists or hepatologists, interventional radiologists, and surgeons. In this article, we present 4 cases that highlight important issues and considerations in the evaluation of SpVT, including initial diagnostic approach in a patient with a new diagnosis of SpVT, considerations for anticoagulant therapy, management of SpVT in patients with myeloproliferative neoplasms, and the role of interventional vascular procedures in the management of SpVT. By reviewing the current literature, we address clinically relevant questions that are posed to clinicians managing patients with SpVT; we also point out gaps in our current knowledge that merit future investigation.

Portal hypertension: recommendations for diagnosis and treatment. Consensus document sponsored by the Spanish Association for the Study of the Liver (AEEH) and the Biomedical Research Network Centre for Liver and Digestive Diseases (CIBERehd)

Portal hypertension is a hemodynamic abnormality that complicates the course of cirrhosis, as well as other diseases that affect the portal venous circulation. The development of portal hypertension compromises prognosis, especially when it rises above a certain threshold known as clinically significant portal hypertension (CSPH). In the consensus conference on Portal Hypertension promoted by the Spanish Association for the Study of the Liver and the Hepatic and Digestive diseases area of the Biomedical Research Networking Center (CIBERehd), different aspects of the diagnosis and treatment of portal hypertension caused by cirrhosis or other diseases were discussed. The outcome of this discussion was a set of recommendations that achieved varying degrees of consensus among panelists and are reflected in this consensus document. The six areas under discussion were: the relevance of CSPH and the non-invasive methods used for its diagnosis and that of cirrhosis, the prevention of the first episode of decompensation and its recurrence, the treatment of acute variceal bleeding and other complications of portal hypertension, the indications for the use of TIPS, and finally, the diagnosis and treatment of liver vascular diseases.

Portal hypertension: recommendations for diagnosis and treatment. Consensus document sponsored by the Spanish Association for the Study of the Liver (AEEH) and the Biomedical Research Network Center for Liver and Digestive Diseases (CIBERehd)

Portal hypertension is a hemodynamic abnormality that complicates the course of cirrhosis, as well as other diseases that affect the portal venous circulation. The development of portal hypertension compromises prognosis, especially when it rises above a certain threshold known as clinically significant portal hypertension (CSPH). In the consensus conference on Portal Hypertension promoted by the Spanish Association for the Study of the Liver and the Hepatic and Digestive diseases area of the Biomedical Research Networking Center (CIBERehd), different aspects of the diagnosis and treatment of portal hypertension caused by cirrhosis or other diseases were discussed. The outcome of this discussion was a set of recommendations that achieved varying degrees of consensus among panelists and are reflected in this consensus document. The six areas under discussion were: the relevance of clinically significant portal hypertension and the non-invasive methods used for its diagnosis and that of cirrhosis, the prevention of the first episode of decompensation and its recurrence, the treatment of acute variceal bleeding and other complications of portal hypertension, the indications for the use of TIPS, and finally, the diagnosis and treatment of liver vascular diseases.

The evolution of the TIPS placement technique and its applications over four decades

Transjugular intrahepatic portosystemic shunt (TIPS), a highly effective procedure reducing portal hypertension, has been in use for over seven decades and is now a cornerstone in managing portal hypertension-related complications such as variceal bleeding and ascites. Historically, TIPS has dealt with two main challenges: ensuring stent patency and preventing post-TIPS hepatic encephalopathy. The introduction of PTFE-coated stents markedly reduced the risk of TIPS dysfunction and stent patency is no longer a major concern. However, despite improved patient selection criteria, hepatic encephalopathy continues to be a significant and persistent issue. In addition, the broader application of TIPS in recent decades has brought to light additional, albeit less common, complications, such as post-TIPS heart failure. This review offers a comprehensive overview of TIPS historical evolution, advancements in technique, and its application in the treatment of portal hypertension.

Surgical Management of Infective Endocarditis Complicated by Budd-Chiari Syndrome

Budd-Chiari syndrome (BCS) is a relatively rare comorbidity, particularly in patients undergoing cardiac surgery. The difficulty arises when we try to drain blood from the obstructed lower body circulation to establish extracorporeal circulation. Herein, we describe a patient who developed a persistent fever after undergoing neurosurgery for a head arteriovenous fistula, wherein blood cultures confirmed Staphylococcus aureus infection. The patient exhibited hyperbilirubinemia, hyperammonemia, and transient loss of consciousness. Transthoracic echocardiography showed moderate mitral regurgitation and 3 cm vegetation on the mitral valve. Imaging identified a thrombus in the right hepatic vein, stenosis of both the inferior vena cava and left hepatic vein, and esophagogastric and splenic varices. These findings led to establishing a diagnosis of infective endocarditis and BCS. The patient subsequently underwent mitral valve replacement with a mechanical valve. There are only a few case reports describing successful cardiac surgery in patients with BCS. Hence, we would like to report our surgical treatment of infective endocarditis complicated with BCS.

Point-of-care ultrasound in the diagnosis and treatment of Budd-Chiari syndrome: A rare case report and literature review

Budd-Chiari syndrome (BCS) is a life-threatening disease characterized by the partial or complete obstruction of hepatic venous outflow anywhere from the liver to the heart. In China, secondary BCS is rare. We present a case of secondary BCS caused by compression of the suprahepatic inferior vena cava (IVC), mainly due to local bile accumulation in the caudate lobe of the liver. This case highlights the scarcity of secondary BCS worldwide and the importance of point-of-care ultrasound (POCUS) in the diagnosis and treatment, especially in critical and comatose patients. Prompt diagnosis and recanalization with POCUS-guided puncture and drainage help improve patient prognosis.

Venous outflow reconstruction in living-donor liver transplantation for Budd-Chiari syndrome involving vena cava

Ironically, the hepatic vena cava is mostly involved in Budd-Chiari syndrome in the Asia-Pacific region, whereas living-donor liver transplantation is predominant, which cannot replace the hepatic cava. Hata and colleagues introduced a new surgical technique for venous reconstruction in living-donor liver transplantation, providing a novel solution to this longstanding dilemma.

Splanchnic Vein Thrombosis: The State-of-the-Art on Anticoagulant Treatment

Splanchnic vein thrombosis (SVT) is a rare type of venous thromboembolism occurring within the splanchnic venous system. Portal vein thrombosis is the most common presentation, while Budd-Chiari syndrome is the least common. Liver cirrhosis and abdominal solid cancer are the main local risk factors for SVT, whereas myeloproliferative neoplasms are the predominant systemic risk factors. Signs and symptoms of SVT are nonspecific and include abdominal pain, gastrointestinal bleeding, and ascites. Asymptomatic SVT is not uncommon, and the majority would be detected incidentally on routine abdominal imaging performed for the follow-up of liver diseases and tumors. The management of SVT aims to prevent thrombus progression, promote vessel recanalization, and prevent recurrent venous thromboembolism. Anticoagulation should be started early in order to increase the chances of vessel recanalization and reduce the risk of portal hypertension-related complications. Direct oral anticoagulants have been included in recent guidelines, as alternatives to vitamin K antagonists, after clinical stability has been reached; however, caution is required in patients with liver or kidney dysfunction. Treatment duration is based on the presence (or absence) and type (transient vs. permanent) of risk factors. This narrative review aims to summarize the latest evidence on SVT, with a particular focus on the anticoagulant treatment in special categories of patients (e.g., liver cirrhosis, solid cancer, myeloproliferative neoplasms, pancreatitis, incidentally detected SVT, Budd-Chiari syndrome, and chronic SVT).

A Case of Budd-Chiari Syndrome Secondary to Tumor Thrombosis

Budd-Chiari syndrome (BCS) is a rare constellation of conditions due to obstruction of venous flow from anatomical levels ranging from the hepatic veins to the confluence of the inferior vena cava (IVC) and right atrium. The resulting retrograde flow of blood leads to hepatomegaly, ascites, and liver failure among other features. Our case highlights the clinical features, diagnostic challenges, and management of a patient with a tumor thrombus from a metastatic prostate adenocarcinoma in a 67-year-old male leading to BCS. This patient, with a past history of prostate adenocarcinoma and aortic valve replacement on chronic warfarin anticoagulation, presented with acutely worsening abdominal pain and a distended abdomen, and imaging revealed an IVC filling defect. Subsequent imaging with a piflufolastat prostate-specific PET showing increased uptake in the IVC elucidated the diagnosis of tumor thrombosis. Management considerations include aggressive therapy and optimization of quality of life. The patient was offered both options, and options including surgical shunting, bypasses, and anticoagulation were discussed. After shared decision-making, the patient and family opted to choose the pathway of palliative radiation and anticoagulation.

Transjugular Intrahepatic Portosystemic Shunt in Nonmalignant Noncirrhotic Portal Vein Thrombosis and Portosinusoidal Vascular Disorder

Transjugular intrahepatic portosystemic shunt (TIPS) emerges as a key treatment for portal hypertension (PH) complications. While international guidelines provide clear indications for its use in cirrhosis, empirical knowledge is notably scarcer in non-cirrhotic PH, particularly in nonmalignant noncirrhotic portal vein thrombosis (NNPVT) and in patients with portosinusoidal vascular disorder (PSVD). Patients afflicted by these rare diseases exhibit distinct clinical profiles compared to their cirrhotic counterparts, often characterized by a younger age, predominantly preserved hepatic functionality even in cases of severe PH, and a higher propensity for extensive splanchnic thrombosis, which intricately complicates TIPS placement, posing unique challenges for its creation. The objective of this review is to synthesize existing literature on the effectiveness, safety, specific indications, and clinical outcomes of TIPS in adult patients with NNPVT or PSVD, focusing also on the technical challenges of TIPS insertion in the presence of portal cavernoma.

[Splanchnic vein thrombosis]

Splanchnic vein thrombosis includes Budd-Chiari syndrome and portal vein thrombosis. These diseases share common features: (i) they are rare diseases and (ii) they can lead to portal hypertension and its complications. Budd-Chiari syndrome and portal vein thrombosis in the absence of underlying liver disease share many risk factors, the most common being myeloproliferative neoplasms. A rapid and comprehensive workup for thrombosis risk factors is necessary in these patients. Long-term anticoagulation is indicated in most patients. Portal vein thrombosis can also develop in patients with cirrhosis, and is associated with a worse course of cirrhosis. Indications for anticoagulation in patients with cirrhosis are increasing. Transjugular intrahepatic portosystemic shunt is a second-line procedure in this setting. Because of the rarity of these diseases, high-level evidence studies are rare. However, collaborative studies have provided a better understanding of their natural history and allowed to improve the management of these patients. This review focuses on the causes, diagnosis, and management of patients with Budd-Chiari syndrome, patients with portal vein thrombosis without underlying liver disease, and patients with cirrhosis and portal vein thrombosis.

CD55 Deficiency With Budd-Chiari Syndrome Treated by Liver Transplantation and Eculizumab

We report the case of a male patient who had a history of early-onset protein-losing enteropathy, chronic diarrhea, and repeated thrombotic events since early childhood. He developed Budd-Chiari syndrome with consequent acute liver failure that required liver transplantation when he was 12 years old. The initial graft failed to function and he required retransplantation. Steroid-resistant rejection complicated the clinical course after the second transplant. Treatment with antithymocyte globulin stabilized graft function but abdominal symptoms and enteral protein loss persisted. The patient remained dependent on intravenous albumin and immunoglobulin. Extended work-up for thrombophilia was unremarkable. Flow cytometry analysis of the peripheral blood cells revealed an unexplained CD55 deficiency. By sequencing of CD55 and, later, exclusion of alternative rare diseases by whole-exome sequencing, we discovered a novel, likely pathogenic homozygous splice-site variant in CD55 c.578 + 5G>A, NM_000574.4, OMIM 125240. The staining of liver and colon biopsies revealed a lack of CD55 protein expression. After initiation of treatment with eculizumab, the patient achieved and has maintained a complete clinical remission throughout 56 months of follow-up. We recommend testing for CD55 deficiency in patients with protein-losing enteropathy. In addition, CD55 deficiency should be considered in the differential diagnosis of patients with Budd-Chiari syndrome in whom an underlying cause is uncertain.

Budd-Chiari Syndrome Caused by Polycythemia Vera: A Case Report

Budd-Chiari syndrome (BCS) is a rare condition characterized by the obstruction of hepatic venous outflow. It has various potential etiologies, with myeloproliferative neoplasms representing the most prevalent pathogenic association. Here, we present the case of a 51-year-old male who manifested abdominal pain and ascites. Subsequent clinical investigation revealed the presence of BCS secondary to a myeloproliferative syndrome, specifically polycythemia vera. This case emphasizes the importance of diagnosing BCS and conducting a thorough investigation into its underlying etiology.

Molecular Mechanisms Underlying Vascular Liver Diseases: Focus on Thrombosis

Vascular liver disorders (VLDs) comprise a wide spectrum of clinical-pathological entities that primarily affect the hepatic vascular system of both cirrhotic and non-cirrhotic patients. VLDs more frequently involve the portal and the hepatic veins, as well as liver sinusoids, resulting in an imbalance of liver homeostasis with serious consequences, such as the development of portal hypertension and liver fibrosis. Surprisingly, many VLDs are characterized by a prothrombotic phenotype. The molecular mechanisms that cause thrombosis in VLD are only partially explained by the alteration in the Virchow's triad (hypercoagulability, blood stasis, and endothelial damage) and nowadays their pathogenesis is incompletely described and understood. Studies about this topic have been hampered by the low incidence of VLDs in the general population and by the absence of suitable animal models. Recently, the role of coagulation imbalance in liver disease has been postulated as one of the main mechanisms linked to fibrogenesis, so a novel interest in vascular alterations of the liver has been renewed. This review provides a detailed analysis of the current knowledge of molecular mechanisms of VLD. We also focus on the promising role of anticoagulation as a strategy to prevent liver complications and to improve the outcome of these patients.

Focal Liver Lesions in Budd-Chiari Syndrome: Spectrum of Imaging Findings

Budd-Chiari syndrome (BCS) is a rare clinical entity characterized by hepatic venous outflow obstruction, resulting in liver congestion and subsequent chronic parenchymal damage. This condition often leads to the development of focal liver lesions, including benign focal nodular hyperplasia-like regenerative nodules, hepatocellular carcinoma, and perfusion-related pseudo-lesions. Computed tomography, ultrasound, and magnetic resonance are the commonly employed imaging modalities for the follow-up of BCS patients and for the detection and characterization of new-onset lesions. The accurate differentiation between benign and malignant nodules is crucial for optimal patient management and treatment planning. However, it can be challenging due to the variable and overlapping characteristics observed. This review aims to provide a comprehensive overview of the imaging features and differential diagnosis of focal liver lesions in BCS, emphasizing the key findings and discussing the challenges associated with their interpretation, with the purpose of facilitating the subsequent clinical decision-making.

Rhabdoid meningioma with a history of Budd-Chiari syndrome: a case report and review of the literature

Background

Rhabdoid meningioma and Budd-Chiari syndrome are both extremely rare, and there is no report describing the two diseases occurring in the same patient thus far. Herein, we showed an unusual case of rhabdoid meningioma with a history of Budd-Chiari syndrome.

Case presentation

The man was found to have abnormal liver function during physical examination in 2016 at 36 and was not paid attention to it. In 2019, he went to Beijing YouAn Hospital Affiliated to Capital Medical University for the decompensation of cirrhosis and was diagnosed with Budd-Chiari syndrome, subsequent angiography of the inferior vena cava combined with balloon dilatation were performed, the anticoagulation and hepatoprotective therapy were performed for a long time. When he turned 40 who had magnetic resonance imaging (MRI) that showed a left frontotemporal lobe space-occupying lesion, and postoperative pathological examination confirmed rhabdoid meningioma. He underwent surgery and postoperative adjuvant radiotherapy, but then he developed severe psychiatric symptoms and eventually succumbed to a lung infection two months after treatment.

Conclusions

Budd-Chiari syndrome and Rhabdoid meningiomas are both extremely rare diseases. To the best of our knowledge, there is no report that the two rare diseases occurred in the same patient, and this is the first case. However, whether there is any link between the two diseases is unclear, more researches are needed to confirm it in the future.