budd chiari syndrome01ppt
TRANSCRIPT
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Budd-Chiari syndrome
By Ahmed Abdulghany
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INTRODUCTION
Pathophysiologic process that results in an interruption or diminution of the normal flow of blood out of the liver, However, as commonly used, the Budd-Chiari syndrome implies thrombosis of the hepatic veins and/or the intrahepatic or suprahepatic inferior vena cava.
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ETIOLOGY
• An underlying disorder can be identified in
over 80 % of patients with the Budd-Chiarisyndrome.
• More than one thrombotic risk factors are present in many patients; 46 % had more than one risk factor in one series
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A 2009 guideline from the American Association for the Study of Liver Diseases recommends the following approach for investigating causes of Budd-Chiari Syndrome:
• Evaluate for space occupying lesions or malignant tumors compressing or invading the hepatic venous outflow tract with sonography, CT scan, or MRI.
• Seek evidence for ulcerative colitis, celiac disease, and systemic diseases.
• Routinely evaluate for multiple, concurrent risk factors for thrombosis.
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CLINICAL MANIFESTATIONS
One of the largest published series included a total of 237 patients who had been treated at four centers (in the United States, the Netherlands, and France) between 1984 and 2001. The following observations were made:
• The median age was 35 (range 13 to 76)
• 67 % were female
• An overt myeloproliferative disorder was present in 23 % (the majority of whom had polycythemia vera)
• The two most common symptoms were ascites (84 %) and hepatomegaly (76 %); 11 patients (5 %) were asymptomatic
• The hepatic outflow obstruction was in the hepatic veins (62 %) inferior vena cava (7 %) or both (31 %); 34 patients (14 %) had associated portal vein thrombosis
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Acute disease
• Commonly in women.• Patients usually present with severe right upper
quadrant pain • Hepatomegaly, Jaundice and ascites often develop
rapidly. • Ascites is detectable by ultrasound in more than 90
% of patients. Variceal bleeding may also occur• Serum aminotransferase concentrations can range
from 100 to 200 int. unit/L to more than 600 int. unit/L
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Subacute and chronic disease
• Present for several weeks to more than six months prior to clinical presentation
• Hypertrophy of the caudate lobe of the liver
• Cirrhosis may have developed in the chronically congested liver.
• Patients may then develop ascites, which may be massive.
• Hepatomegaly and abdominal pain are also common.
• Encephalopathy is infrequent.
• Hepatopulmonary syndrome has been described in up to 28 % of patients.
• Normal or mild to moderate elevation of serum aminotransferases, alkaline phosphat.
• Jaundice is rare.
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DIAGNOSIS
• Doppler ultrasonography
• CT scan
• Magnetic resonance imaging
• Venography
• Liver biopsy
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liver biopsy
In 2009 AASLD recommended liver biopsy ONLY when hepatic venous outflow obstruction cannot be demonstrated by non invasive imaging
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Medical therapy
• Supportive: ascites
• Anticoagulation: AASLD recommend anticoagulation only in patients with chronic and subacute disease with well compensated liver.
• Thrombolytic therapy: NOT in chronic BuddChiari and ONLY in patients in whom the clot is well defined on venography
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Surgical options
• Angioplasty
• TIPS
• Surgical shunts
• Liver Transplantation
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Thank you