Pdf

1
Pediatric Budd Chiari Syndrome secondary to
hepatic tuberculosis and its endovascular
management.

• Alamelu Alagappan1, Ranjan K Patel1, Taraprasad
  Tripathy1, Amit K Satpathy2, Krishna M Gulla2,
  Abhilash2, Nerbadyswari Deep(Bag)1
• 1.Department of Radiodiagnosis, AIIMS Bhubaneswar
• 2.Department of Pediatrics, AIIMS Bhubaneswar

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Introduction

• Budd Chiari Syndrome (BCS) is characterized by
  hepatic venous outflow obstruction.
• Most common cause - underlying hypercoagulable
  state or membrane.
• Other causes - extra hepatic or intra hepatic
  space occupying lesion compressing or invading
  the venous outflow.
• BCS due to hepatic tuberculosis is rare.
• Here we present a case of BCS due to hepatic
  venous obstruction by hepatic parenchymal
  tubercular lesions.

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Case report

• A 14 year young toddler presented to Emergency
  Department with progressive abdominal distension
  and dyspnea.
• Icterus, abdominal tenderness and distension with
  shifting dullness was present.
• Ultrasonography Large hypoechoic lesion in
  caudate lobe causing occlusion of left hepatic
  vein.
• Doppler- Monophasic flow in left hepatic vein.

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A
B
C
Figure 1 USG image showing A) hypoechoic lesion
B) monophasic flow in left hepatic vein C)
intrahepatic veno venous collaterals.
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• Contrast Enhanced Computed Tomography (CECT) -
  Multiple heterogeneous lesions with internal foci
  of calcifications.
• Multiple abdominal wall collaterals, enlarged and
  conglomerate necrotic retroperitoneal nodes were
  seen.
• Radiological diagnosis - Budd Chiari Syndrome
  secondary to hepatic tuberculosis.
• Biopsy - proved hepatic tuberculosis.
• Anti Tubercular Treatment (ATT) started - no
  clinical improvement. Plan - hepatic venous angio
  plasty.

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A
B
Figure 2 CECT images showing A) heterogeneously
enhancing liver lesions with multiple internal
foci of calcifications (arrows) B) necrotic
calcified retroperitoneal lymph nodes (arrow
head)
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PERCUTANEOUS HEPATIC VEIN ACCESS
GUIDEWIRE INTRODUCED INTO IVC
TRANSJUGULAR SNARE TECHNIQUE TO CAPTURE GUIDEWIRE
GUIDEWIRE PULLED OUT OF JUGULAR VEIN
BALLOON ANGIOPLASTY AND STENTING
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B
C
A
Figure 3 A) Steps in hepatic vein angioplasty B)
Percutaneous hepatic vein access C) Snare
technique D) Balloon dilatation and stenting E)
Post stenting
D
E
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Discussion

• Hepatic tuberculosis diffuse pattern of
  parenchymal involvement
• Underlying liver parenchymal lesion tends to mask
  the typical findings of BCS.
• In addition to this, ATT itself confounds the
  diagnosis, given its risk of hepatotoxicity.
• Management of Budd Chiari Syndrome depends on
  disease duration and severity.
• Treatment options include thrombolysis,
  angioplasty/stenting, TIPS or liver
  transplantation.

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Conclusion

• BCS due to hepatic tuberculosis is very rare.
• The nature, location and extension of the
  obstruction can be diagnosed on real time and
  cross sectional imaging modalities.
• Hepatic venous angioplasty acts as a potential
  pathway of recanalization in these patients.
• Residual stenosis despite angioplasty
  necessitates stenting as performed in our case.

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References

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