Budd-Chiari Syndrome

Hepatic injury due to global or segmental hepatic venous outflow or inferior vena cava (IVC) obstruction

Multiphasic CT, or MR [± gadoxetate (Eovist) enhancement]

• Characteristic findings: Nodular regenerative hyperplasia in dysmorphic liver with venous collateral and ascites

• Hypertrophied caudate lobe with atrophy and necrosis of peripheral liver ("pseudotumor")

• Intrahepatic and systemic venous collaterals bypass obstructed hepatic veins and IVC

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    Spider web pattern of hepatic venous collaterals on CT, MR, angiography

• Large regenerative nodules (form of nodular regenerative hyperplasia) are characteristic of chronic Budd-Chiari syndrome (BCS)

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    Imaging and histology are similar to FNH

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    May have peripheral halo and central scar

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    Hypervascularity persists into venous phase, usually without washout

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    Uniform or peripheral delayed retention (bright) on gadoxetate-enhanced MR

US

• Absent, reversed, or flat flow in hepatic veins; reversed flow in IVC on color Doppler US

• Venovenous collaterals

• Heterogeneous liver parenchyma

Do not mistake BCS for cirrhosis

• Pathogenesis, imaging findings, prognosis, and treatment are very different

Do not mistake caudate hypertrophy or large regenerative nodules for hepatocellular carcinoma

Check for hypercoagulable conditions (most common cause)

Budd-Chiari syndrome (BCS)

Hepatic venous outflow obstruction

Global or segmental hepatic venous outflow obstruction

• At level of large hepatic veins or suprahepatic segment of inferior vena cava (IVC)

Best diagnostic clue

• Caudate hypertrophy, peripheral atrophy, ascites, and collateral veins bypassing occluded IVC

Location

• Hepatic veins, IVC, or centrilobular veins

Characteristic finding: Nodular regenerative hyperplasia in dysmorphic liver