Ultrasound appearances of Budd–Chiari syndrome

In the acute stage, the liver may enlarge. As the condition progresses, compensatory hypertrophy of any ‘spared’ segments occurs—usually the caudate lobe, because the venous drainage from here is inferior to the main hepatic veins. The hepatic veins may be difficult or impossible to visualize (Fig. 4.26).
image
Ultrasound images Budd–Chiari syndrome (BCS). The MHV
is tortuous and strictured, and difficult to identify on
ultrasound.
image
Ultrasound images Large collaterals are seen (arrows) near
the surface of the liver in BCS.
image
Ultrasound images Tumour thrombus
from a renal carcinoma occludes the inferior vena cava
(IVC), causing BCS.
Dilated serpiginous collateral veins may form to direct blood away from the liver and in some cases the portal venous flow reverses to achieve this. The
spleen also progressively enlarges and, if the disease is long-standing, the liver becomes cirrhotic, acquiring a coarse texture.
Ascites may also be present, particularly if there is complete obstruction involving the IVC. The cause of IVC obstruction may be a web, which can
occasionally be identified on ultrasound. If the cause of BCS is a coagulation disorder, the portal venous system may also be affected by thrombosis,
causing portal hypertension. Doppler is particularly helpful in diagnosing BCS. The hepatic veins and IVC may be totally.
or partially occluded; if partial, the waveforms may become flattened, losing their characteristic triphasic pattern. In some cases flow may be reversed in
the IVC, hepatic and/or portal veins. Ultrasound may miss partial hepatic vein occlusion, but the use of contrast agents in suspected cases of BCS may
improve diagnostic accuracy.
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