Chronic Budd–Chiari Syndrome and Abdominal Varices

A 44-year-old man with a 20-year history of chronic liver disease presented with recurrent acute upper gastrointestinal bleeding and worsening mental status. He was emaciated, with marked abdominal distention due to ascites, and had prominent superficial veins over the anterior abdominal wall, with flow directed upward. Liver-function tests were elevated, with an aspartate aminotransferase level of 240 U per liter (normal range, 0 to 35), an alanine aminotransferase level of 367 U per liter (normal range, 0 to 35), a total bilirubin level of 4.6 mg per deciliter (78.7 µmol per liter) (normal range, 0.3 to 1.0 [5.1 to 17.1]), and an albumin level of 1.8 g per deciliter (normal range, 3.5 to 5.5). Upper gastrointestinal endoscopy showed large esophagogastric varices and portal gastropathy. Computed tomography revealed a suprahepatic inferior vena caval web. Severe portal hypertension with variceal bleeding and encephalopathy due to cirrhosis of the liver may be caused by chronic obstruction of the hepatic venous outflow tract, such as that which may occur as a result of an inferior vena caval web. An inferior vena caval web is a not-uncommon cause of chronic (or acute) Budd–Chiari syndrome in India. In this case, percutaneous transfemoral recanalization of the inferior vena caval web was attempted but failed. The patient died at home from variceal bleeding a few days later.