This document presents a case report of a 20-year-old female student who presented with abdominal distention, jaundice, and pain while urinating. Various tests were performed, including bloodwork, ultrasound, and biopsy. The final diagnosis was portal vein and splenic vein thrombosis due to a hypercoagulable state from essential thrombocythemia, exacerbated by oral contraceptive use. The document also reviews several other case reports and discusses vascular diseases of the liver like Budd-Chiari syndrome.

1. Case presentation: Dr. Mohammad Shaikhani. Dr. Mohammad Omer Mohammad. Sulaimanyah University. College of Medicine. Department of Medicine.

2. SH.K, 20 years old, Studen from Darbandixan,Sulaimanyiah, Iraq. Date of admission: 9.9.08 CC: abdominal distention for the last 2 weeks H.P.I: a female with abdominal distention and yellow discoloration of skin and sclera associated with pain during voiding and frequency with lower pelvic pain. There were no fever no rigor. P.M.H: not significant D.H: on HRT for irregular cycles. There is no Hx of blood transfusion, tattooing or drug injection “ addiction ”

3. Review of systems: Resp: SOB, no cough no sputum CVS: no palpitation, no leg edema. GIT: decr. Appetite, nausea, constipation. O/E: conscious oriented young lady Ting of jaundice, no cyanosis … mild pallor Chest: clear, N.V.B Precordium: NDR, no added sounds Abdomen: soft, hepatospleenomegally Ascitis with +ve shifting dullness and trans thrill Neurology: intact Vita signs …

4. Ix: LFT: Bilirubin 0.9 , 0.7 Alk. Phosphatase: 87 , 69 S. GOT: 8 , 26 S.GPT: 5 , 25 T.S.P: 7.6 , 7.7 PT: 21.7 sec , INR: 2.4 - 19.5 INR: 2.0 PCV: 42 , 37 CBP: Hb: 13.2 – MCV: 39.8 – MCH: 22.0 – MCHC: 33.3 – WBC: 4200 , 8700 – 80% N 17% L – PLT: 586.000

5. Bl. Film: RBC: normochromic normocytic screeninig for infection & infl. Disorders. WBC: Neutrophilia, Lymphopenia. Platelet: Markedly increased. ESR: 11 ,14 GUE … U/S: mild liver enlargement, coarse texture no focal lesion, mod-severe large spleen mod. Amount of ascitis.

6. Ascetic fluid aspiration: WBC = lymphocytosis Ptn= 4.5,4.8 Sugar= 100 AFB: negative Cytology= LC, no malignant cells ANA and AMC Ab Ads DNA Ab A LKM … -VE ANTILIVER KIDNEY MICROSOME= -VE Viral marker= -ve (twice) OGD= esophagitis, gastritis Peritoneal biopsy: no granuloma, no malig.

7. S. Copper: 150Mg Ceruloplasmin: 36.3mg RBS: 126 , RFT: Bl U: 11 , S Creat: 0.5 SGPT: 13 , SGOT: 18 , PT: 20.6 , INR: 2.1 Ascitic Fluid: Lymphocytosis: 70% , Pr: 5.2 Sug: 120 , no AFB CBP: Hb: 12.7 – MCV: 65.9 - MCH: 21.9 – MCHC: 33.3 – WBC: 13600 – PLT:813.000 Bl. Film: RBC: hypochromic microcytic anisopoikilocytosis elliptocytosis. WBC:mild Neutrophilia. Platelet: Markedly increased with anisothrombia many Giant cells seen.

8. S Pr. Elec: AlB: normal 58.20 Alpha 1: low 0.07 Alpha 2: low 3.65 Beta: low 6.62 Gama: high 31.46 Total: 8.20 gm/dl A/G : 1.39

9. Doppler study: 1 st : prominent caudate lobe, mild coarse liver texture, nr hepatic flow 2 nd : hepatomegaly, prominent caudate, no focal mass, acute thrombosis of portal and splenic vein. Huge splenomegaly and moderate abdominal Ascitis. Last PT: 24.7 INR: 3

10. Final diagnosis: Portal vein/splenic vein thrombosis due to hypercoagulable state from ?essential throbocythemia potentate by oral contraceptive use.

11. OTHER CASE REPORTS FROM INTERNET & LITERETURE:

12. Case 2 52 year old man with a history of PNH originally diagnosed in 1978 (at age 28) when he presented with dark urine and was noted to have moderate hemolytic anemia Treated initially at that time with prednisone and blood transfusions. Had a relatively mild course with infrequent episodes of hematuria and very few blood transfusions Did not see a hematologist for over 20 years

13. Case Presentation Presented in April 2002 with abdominal pain and distension and was noted to be jaundiced Hepatitis workup was negative but an MRI of the abdomen revealed hepatic vein thrombosis (Budd-Chiari syndrome) Underwent a transjugular liver biopsy on 4/23/02 which revealed extensive fibrosis, no cirrhosis, sinusoidal dilatation and central vein fibrosis consistent with Budd-Chiari syndrome Despite anticoagulation and numerous paracenteses, refractory ascites was present and he underwent a TIPS procedure in 7/02

14. Case Presentation Patient subsequently developed hepatic encephalopathy, requiring multiple hospital admissions over 2 months following TIPS placement Ultrasounds confirmed patency of shunt Referred to Dr Bessler in 9/02. Evaluation revealed a jaundiced, mildly encephalopathic man with normal abdomen CBC revealed Hgb 11.9 with MCV 97.2, plt cnt 90,000, ANC 2,700, INR 1.7, creatinine 0.8, and bilirubin 6

16. Case: 3

20. Case:4

21. Case: 5,6

22. Case: 1 More cases

24. Vascular diseases of the liver; Budd-chiari/portal vein thrombosis& other veno-occlusive disorders: Conditions in which radiologists & interventional radiologists can contribute much. Prepared by: Dr.Mohammad Shaikhani. [email_address]

35. Diagnosis

40. Management

42. Management

43. Management

46. Etiologies of PVT Cirrhosis is most common - 10-30% 10-50% 40-60% IBD Pregnancy Blunt Trauma OCPs Portocaval Shunt Peptic Ulcer Dz Elevated Homocysteine Protein C/S deficiency Umbilical Vein Catheters Appendicitis Anti-cardiolipin Anti-thrombin III Colectomy Diverticulitis APL syndrome Prothrombin Mutation 20210G/A Splenectomy Pancreatitis Malignancy FVL Liver Transplant Sepsis Acquired Inherited Surgical Inflammatory Thrombophilia Local Factors