Presentation
Recurrent abdominal pain and distension (ascites).
Patient Data
Focal narrowing or waisting of the intrahepatic inferior vena cava with a linear filling defect.
Hepatomegaly, including the caudate lobe, and heterogeneous enhancement of the liver parenchyma. Segment V is notably hypodense to the rest of the liver. Also, multiple small nodules are seen throughout the liver.
The hepatic veins are not visualized. The portal vein is normal in caliber and enhances homogeneously. There are few collateral vessels (e.g. hepatorenal, recanalized umbilical vein).
Splenomegaly.
Ascites.
The arrow shows the focal narrowing of the inferior vena cava.
Case Discussion
The patient had abdominal pain, ascites and hepatomegaly: a triad classically seen with Budd-Chiari syndrome (BCS) or hepatic venous outflow obstruction. BCS has many etiologies, and this CT directly shows one of the uncommon causes: inferior vena cava web.
An IVC web can be congenital, or more commonly, a sequel of prior thrombosis.
This patient underwent inferior venacavography (images not available) which confirmed an IVC web, and angioplasty was performed thereafter.
The liver parenchymal nodules, volume redistribution (e.g. caudate hypertrophy), and features of portal hypertension (e.g. splenomegaly, collaterals), are typically seen with chronic BCS.
Although the hepatic nodules are likely regenarative, hepatocellular carcinoma remains a concern, and cannot be reliably ruled out on a monophasic study. The ideal imaging evaluation of such a case must include liver protocol CT or MRI.
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