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Fig. 1A —45-year-old woman with 1-month history of weakness and
enlargement of abdominal diameter. Gray-scale sonogram obtained in right
subcostal plane shows echogenic bands replacing right and left hepatic veins
(open arrowheads) and failed to show middle hepatic vein. Liver
parenchyma is heterogeneous with large central hypoechoic area
(arrows) representing edema caused by congestion. Note perihepatic
ascites. Transjugular intrahepatic portosystemic shunt (TIPS) placement was
mandatory. This case illustrates acute Budd-Chiari syndrome with obstruction
of three major hepatic veins combining signs related to hepatic vein
obstruction and those related to portal hypertension (liver edema and
ascites). However, presence of fibrous cords replacing veins in this acute
setting would support endophlebitis as pathogenic factor.
