A case of Budd Chiari Syndrome.

1. A Case Of Per Abdomen Examination
BY:
Dr. Tikal Kansara
R2 Medicine D Unit

2. Bio Data
• Sajjan Devibhai Balai
• 50 / F
• Hindu
• Illitrate
• Married
• Housewife
• Low socio economic status
• From Borakheda Village, Ujjain, Madhya Pradesh

3. CHIEF COMPLAINS
• Abdominal Distention since 19 years
• Abdominal Pain since 19 years

4. Origin, Duration & Progress
• Abdominal Distention since 19 years
• Abdominal Pain since 19 years
• Yellowish discoloration of urine & sclera 19
years ago
• Swelling of both lower limbs since 19 years
• Dilated Veins over the abdomen since 15 years
• Early Satiety & anorexia since 19 years

5. • No History s/o:
– Malena, Hemetmesis, Bleeding PR, Diarrhoea,
Vomitting
– Burning Micturation, Reduced UOP, Hematuria
– Cough, Hemoptysis, Fever
– Dyspnoea, Chest Pain, Palpitations, Orthopnea,
PND.

6. • PAST HISTORY:
– Hypo pigmented patches over the skin of cheek,
back & soles since childhood
• FAMILY HISTORY:
– Nothing Significant
• PERSONAL HISTORY:
– Nothing Significant
• MENSTRUAL HISTORY:
– Menopausal since last 10 years

7. • OBSTRETIC HISTORY:
G4P3A1L3
– G1 – IUFD @ 7 months
– G2 – M/24/Home/FTND/Vaccinated
– G3 – M/19/Home/FTND/Vaccinated
– G4 – M/15/Home/FTND/Vaccinated

8. HISTORY CONCLUSION
So, at the end of history we have a 50 y/o F with long standing abdominal distention,
discomfort; which have waxing and waning course being partly relieved by
medications, & dilated veins over the abdomen most likely we are dealing with a case
of ‘Ascites From Portal Hypertension’. The differentials (According to Anatomical
Location of Abnormality) would be as follows:
1. Cirrhosis Of Liver
1. Hepatitis B & C Infection
2. Autoimmune Hepatitis (Late Stage)
2. Portal / Splenic Vein Thrombosis
3. Post-Hepatic Obstruction
1. Membranous Webs
2. Myeloproliferative Diseases
3. Anti-Phospholipid Antibody
Syndrome
4. Recurrent Pregnancies
5. Hereditary Thrombophilias

9. GENERAL EXAMINATION
• Patient is conscious, co-operative and well
oriented to time, place & person.
– VITALS
• TPR- N/84/Regular
• BP- 104/62 mmHg
– Hypopigmented patches are present in skin of
chin, back, foot & distal phalanyx of dorsum of
fingers of hands s/o Vitiligo

10. • No pallor, cyanosis, clubbing, icterus, pedal
edema, lymphadenopathy
• No KF Ring visible
• Back & Spine Normal
• No Signs Of Liver Failure present
– No hair loss, parotid enlargement, spider naevi,
dupuytren contracture, palmer erythema.

11. PER ABDOMEN EXAMINATION
• INSPECTION
– Shape of abdomen –
globular
– Umbilicus – Shifted
downwards & inverted
– Dilated & tortuous
veins present over
upper part of the
abdomen and upper
part of the back.

13. • ABDOMINAL MOVEMENTS:
– Bulges during inspiration
• No Abnormal pulsations are visible
• No peristaltic waves visualised
• Skin over the abdomen is lax.

14. • PALPATION:
– Superficial Palpation
• Temperature: Normal
• Non tender abdomen
– Deep Palpation:
• Liver – Not Palpable
• Spleen – Not Palpable
– Dilated Veins over upper abdomen – Flow from
below upwards on milking veins

16. • PERCUSSION:
– Shifting Dullness is present

17. • AUSCULTATION:
– Bowel Sounds audible
– No Bruits, No venous hum

18. OTHER SYSTEM EXAMINATIONS
• RESPIRATORY SYSTEM:
– AEBE
– No Crepts / Rhonchi
• CARDIOVASCULAR EXAMINATION:
– S1;S2 Normal
– No Murmur
• CENTRAL NERVOUS SYSTEM EXAMINATION:
– HF/CN Normal
– Conscious, Cooperative
– No Focal Neurological Deficits
– Tone Normal; Power 5/5 in all four limbs
– PR ↓ / ↓

19. EXAMINATION CONCLUSION
So, from history & physical examination we have a 50 y/o F; with chronic
abdominal distention & discomfort with dilated veins over front and back of
abdomen, which fills from below upwards, without florid signs of liver cell
failure. This is most likely a case of ‘Ascites From Portal Hypertension from
Obstruction likely at the level of Hepatic Veins &/or Inferior Vena Cava’. At this
point, cirrhosis & other differentials seems less likely & post-hepatic
obstruction seems probable enough to label it as Budd-Chiari Syndrome.
Etiology for Budd-Chiari Syndrome at this stage would include:
1. Membranous Webs
2. Anti-Phospholipid Antibody Syndrome
3. Hereditory Thrombophilias
1. Protein C Deficiency
2. Protein S Deficiency
3. Factor V Laden Deficiency
4. Anti Thrombin III Deficiency
4. Myeloproliferative Diseases
5. Recurrent Pregnancies

20. INVESTIGATIONS
• COMPLETE BLOOD COUNT
PARAMETER VALUE NORMAL VALUE
Haemoglobin 12.00 12.0 – 16.0 gm%
Total Counts 6000 4,000 – 11,000 / cumm
Differencials 70 / 28 / 01 / 01
Platelet Count 1.31 lac/ cumm 1.5 – 4.1 lac / cumm
ESR 22 MM 00 – 15 MM
RETICULOCYTE COUNT 0.5 % 0.5 – 2.0 %

21. PARAMETER VALUE NORMAL VALUE
PCV 32.60 36 – 46 %
MCV 79.00 82 – 92 Fl
MCH 29.20 27 – 32 pg
MCHC 36.80 32 – 35 %
SMEAR STUDY
NORMOCYTIC NORMOCHROMIC RBCs

22. • Biochemical Investigations
PARAMETER VALUE NORMAL VALUE
Blood Urea 50 14 – 40 mg/dl
Serum creatinine 0.8 0.1 – 1.2 mg/dl
Bilirubin
Total 1.4 0.1 – 1.2 mg/dl
Direct 0.7 0 – 0.4 mg/dl
Indirect 0.7 0.1 – 0.8 mg/dl
SGPT 20 < 40 U/L
SGOT 42 <37 U/L
ALP 91 28 – 111 IU/L(Adults)
Serum Sodium 136 135 – 145 mmol/L
Serum Potassium 4.5 3.5 – 5.1 mmol/L
Total Protein 8.0 6.0 – 8.0 gm/dl
Serum Albumin 4.8 3.2 – 5.0 gm/dl

23. PARAMETER VALUE
Chest X-Ray Normal
RBS 122 mg%
ECG Grossly WNL

24. ASCITIC FLUID ANALYSIS
PARAMETER VALUE NORMAL VALUE
TOTAL CELLS 320 00 – 05 /cumm
DIFFERENCIALS 60 % / 40 %
PROTEIN 3.6
SUGAR 94

25. • PROTHROMBIN TIME:
• ACTIVATED PARTIAL THROMBOPLASTIN TIME:
PARAMETER VALUE
Prothrombin Time 14.80
Control Time 14.00
INR 1.06
PARAMETER VALUE
PATIENT 30.00
CONTROL 34.00

26. Ultrasound Abdomen
• LIVER:
– Span: 126 mm
– Altered with surface irregularity
– s/o Cirrhosis
• Spleen: 122 mm Spleenomegaly
• Free Fluid: Moderate free fluid in abdomen

27. ULTRASOUND LIVER SCREENING
• Occlusion of terminal IVC
• Entire IVC shows reversal of flow
• Both iliac veins show flow reversal
• Right hepatic vein patent, dilated & sole outflow channel of
the liver
• Left hepatic Vein patent but its ostium is occluded. Flow
drains into right hepatic vein through a prominent collateral
running over liver surface.
• Spleen is not enlarged. Portal and splenic vein shows
normal hepatopetal flow.

28. CECT Abdomen
• Enlarged Caudate lobe and left lobe of liver with
surface nodularity represents Cirrhotic changes.
• Multiple homogenously enhancing nodules of varying
sizes in both lobes represents Regenerating Nodules.
• Marked narrowing of intrahepatic IVC seen. Middle
hepatic vein not visualised. Right and left hepatic veins
visualized.
• Intra-hepatic veno-venous collaterals seen. Multiple
abdominal wall, paraspinal and perioesophageal
collaterals seen.
• Above findings represent Budd-Chiari Syndrome.

29. UGI Scopy
1. GRADE II
OESOPHAGEAL VARICES
PRESENT.
2. CONGESTIVE
GASTROPATHY

30. Viral Markers
PARAMETER VALUE
HIV Non-Reactive
HBsAg Negative
HCV Negative

31. Other Investigations
PARAMETER VALUE
SERUM ANA PROFILE NEGATIVE
PARAMETER VALUE NORMAL VALUE
Serum TSH 4.61 0.35 – 5.50

32. PARAMETER VALUE NORMAL VALUE
Protein C Level 0.66 units/ml
0.55 – 1.11
Units/ml
Protein S Level 0.92 units/ml
0.60 – 1.13
units/ml
Anti Thrombin III
Level
0.23 g/L 0.19 – 0.31 g/L
Factor V Laden 4.6 Units/L 2.0 – 10.0 Units/L
THROMBOPHILIC PROFILE