Diagnostic Ultrasound - Abdomen and Pelvis

Budd-Chiari Syndrome
Diagnoses: Liver
TERMINOLOGY
• Budd-Chiari syndrome (BCS):Hepatic venous outflow
obstruction
• Global or segmental obstruction of hepatic venous outflow
or inferior vena cava (IVC)
IMAGING
• Ultrasound acute phase
○ Absent or restricted flow, possible thrombosis in hepatic
veins (HVs)/IVC
○ Intrahepatic collateralization, bicolored HVs: Flow in
opposite direction in HV branched with a common trunk
○ Reduced velocity, continuous flow in portal vein, possibly
hepatofugal flow
• Ultrasound chronic phase
○ Hypertrophy of caudate lobe and unaffected segments,
atrophy of involved segments, large regenerative
nodules
○ Stenotic or occluded HVs/IVC
KEY FACTS
○ Intrahepatic &/or extrahepatic collateralization
• CECT:"Flip-flop" enhancement pattern
○ Early enhancement of caudate lobe and central portion
around IVC, decreased peripheral liver enhancement
○ Later decreased enhancement centrally and increased
enhancement peripherally
○ Large regenerated nodules, hypertrophic caudate lobe
TOP DIFFERENTIAL DIAGNOSES
• Liver cirrhosis
• Portal vein thrombosis
• Acute, severe passive venous congestion
• Acute hepatitis
DIAGNOSTIC CHECKLIST
• Imaging interpretation pearls
○ Narrowed or obliterated HVs/IVC
○ Bicolored HVs due to intrahepatic collateralization on
color Doppler ultrasound
(Left) Grayscale US of the liver
shows markedly narrowed
right hepatic vein ſt, occluded
more peripherally, and a
narrow inferior vena cava
(IVC) in a patient with
acute Budd-Chiari syndrome.
Associated ascites is present
around the liver . (Right)
Color Doppler US reveals no
detectable flow in the right
hepatic vein with tortuous
intrahepatic collateral vessels
ſt bypassing the occluded
hepatic vein. Note the
tortuous middle hepatic vein
with bicolored appearance st
that cannot be seen
communicating with the IVC.
(Left) Color Doppler US shows
a thrombosed middle hepatic
vein ſt. Note tortuous
collateral flow around
occluded hepatic vein .
(Right) Spectral Doppler
ultrasound in the same patient
demonstrates lack of
detectable flow in middle
hepatic vein ſt on spectral
tracing. Only noise is seen
along the baseline of the
tracing.
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