S2383 When Blood Meets Liver: An Interesting Case of Budd-Chiari Syndrome

Abstract

INTRODUCTION: Budd-Chiari is a syndrome characterized by hepatic venous outflow obstruction. Primary Budd-Chiari is due to pro-coagulant states causing venous thrombosis. Secondary Budd-Chiari is due to compression or invasion of the hepatic veins, such as malignancy. Budd-Chiari is rare and has a high mortality if not properly identified and managed. CASE DESCRIPTION/METHODS: A 67-year-old Hispanic female with past medical history of chronic liver mass, liver cirrhosis secondary to NAFLD, type 2 diabetes mellitus, and obesity, presents with abdominal pain for several days. Physical exam was notable for right upper quadrant abdominal pain, anasarca, and abdominal wall cellulitis. Laboratory tests were remarkable for white blood cell count, 3.2; platelet count, 84; and AST 66. The remainder of laboratory data were unremarkable. CT abdomen pelvis showed enlarging right hepatic lobe lesion; expansion of the right hepatic vein into the suprahepatic IVC, concerning for tumor thrombus; and infrahepatic IVC prominent caliber suggestive of backflow pressure related to tumor thrombus. MRI abdomen showed 4.2 cm mass in the right hepatic lobe, possibly hepatocellular carcinoma. The location of the mass did not allow for safe percutaneous biopsy. Tumor marker AFP was noted to be 1,682. Hypercoagulable panel and immunologic work up were unremarkable. The patient was started on IV heparin and IV antibiotics. She was eventually transitioned to by mouth Eliquis. After a 14-day hospital stay, she was discharged home on continued Eliquis treatment and outpatient follow up appointments with Gastroenterology and Hematology. DISCUSSION: The presentation of Budd-Chiari is highly variable. When considering the diagnosis clinicians should be suspicious of patients with risk factors, such as malignancy, hypercoagulable states, and liver infections. Typical signs and symptoms of Budd-Chiari include acute liver failure patients with ascites, right upper quadrant abdominal pain, and hepatomegaly. The diagnosis is generally made with imaging. Abdominal ultrasound may show hypertrophied caudate liver lobe secondary to venous outflow channels distinct from the hepatic veins. CT or MRI abdomen can provide confirmatory imaging if ultrasound is unremarkable, but suspicion is high. Liver biopsy is not required to establish diagnosis and increases risk of bleeding. Although there are significant bleeding risks in patients, long term anticoagulation is required.