A 31yr old lady presents to the emergency department overnight with acute abdominal pain. She has no significant history besides being on the oral contraceptive pill. On CT her liver appears mottled, with decreased peripheral enhancement. The caudate lobe is noted to be enlarged, but enhances normally. There is a small volume of ascites. Given these findings, occlusion of which structure is the most likely cause?
Hepatic Artery | |
Hepatic Veins | |
Portal Vein | |
Bile ducts | |
Lymphatic drainage to the liver |
The pattern of inhomegnous mottling of the liver, with reduced peripheral enhancement and caudate enlargement is typical of Budd-Chiari Syndrome (Hepatic vein occlusion). Clinically it can present acutely with abdominal pain, hepatomegaly and ascites, however with most patients it is slower onset, and can be painless. The lack of venous drainage causes the liver to become congested, which causes reduced (or reversed) portal venous flow. This means peripheral enhancement is reduced. The caudate lobe is often spared as it has seperate anastamoses to the IVC. Obviously the finding to look for on imaging is occlusion to the hepatic veins/IVC.
The other named structures, if occluded, would not typically give this assortment of findings.
References
http://radiopaedia.org/articles/budd-chiari-syndrome-1
Budd-Chiari syndrome: Spectrum of imaging findings: http://www.ajronline.org/doi/pdf/10.2214/AJR.05.0168