Budd-Chiari syndrome differential diagnosis

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Editor-In-Chief: C. Michael Gibson, M.S., M.D. [1]; Associate Editor(s)-in-Chief: Mazia Fatima, MBBS [2] Amandeep Singh M.D.[3]

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Overview

Differential diagnosis

Abbreviations: RUQ= Right upper quadrant of the abdomen, LUQ= Left upper quadrant, LLQ= Left lower quadrant, RLQ= Right lower quadrant, LFT= Liver function test, SIRS= Systemic inflammatory response syndrome, ERCP= Endoscopic retrograde cholangiopancreatography, IV= Intravenous, N= Normal, AMA= Anti mitochondrial antibodies, LDH= Lactate dehydrogenase, GI= Gastrointestinal, CXR= Chest X ray, IgA= Immunoglobulin A, IgG= Immunoglobulin G, IgM= Immunoglobulin M, CT= Computed tomography, PMN= Polymorphonuclear cells, ESR= Erythrocyte sedimentation rate, CRP= C-reactive protein

Classification of acute abdomen based on etiology Disease Clinical manifestations Diagnosis Comments
Symptoms Signs
Fever Rigors and chills Abdominal Pain Jaundice Hypo-

tension

Guarding Rebound Tenderness Bowel sounds Lab Findings Imaging
Abdominal causes Inflammatory causes Pancreato-biliary disorders Acute suppurative cholangitis + + RUQ + + + + N
  • Abnormal LFT
  • WBC >10,000
Ultrasound shows biliary dilatation/stents/tumor Septic shock occurs with features of SIRS
Acute cholangitis + RUQ + N Abnormal LFT Ultrasound shows biliary dilatation/stents/tumor Biliary drainage (ERCP) + IV antibiotics
Acute cholecystitis + RUQ + Hypoactive Ultrasound shows gallstone and evidence of inflammation Murphy’s sign
Acute pancreatitis + Epigastric ± ± N Increased amylase / lipase Ultrasound shows evidence of inflammation Pain radiation to back
Primary biliary cirrhosis RUQ/Epigastric + N Increased AMA level, abnormal LFTs
Primary sclerosing cholangitis + RUQ + N
Cholelithiasis ± RUQ/Epigastric ± + + N to hyperactive for dislodged stone Leukocytosis Ultrasound shows gallstone Murphy’s sign
Gastric causes Peptic ulcer disease ± Diffuse + in perforated + + N
  • Ascitic fluid
    • LDH > serum LDH
    • Glucose < 50mg/dl
    • Total protein > 1g/dl
Air under diaphragm in upright CXR Upper GI endoscopy for diagnosis
Gastritis ± Epigastric
Gastroesophageal reflux disease Epigastric
Gastric outlet obstruction Epigastric ± Hyperactive
Gastrointestinal perforation + ± Diffuse ± + + ± WBC> 10,000 Air under diaphragm in upright CXR
Intestinal causes Acute appendicitis + +in pyogenic appendicitis Starts in epigastrium, migrates to RLQ + in perforated appendicitis + + Hypoactive Leukocytosis Ultrasound shows evidence of inflammation Nausea & vomiting, decreased appetite
Acute diverticulitis + ± LLQ + Hypoactive Leukocytosis CT scan and ultrasound shows evidence of inflammation
Inflammatory bowel disease ± Diffuse
Irritable bowel syndrome ± Diffuse N Tests done to exclude other diseases as it diagnosis of exclusion Tests done to exclude other diseases as it diagnosis of exclusion Symptomatic treatment
Whipple's disease ± Diffuse ± ± N *Endoscopy is used to confirm diagnosis.

Images used to find complications

Extra intestinal findings:
Toxic megacolon + Diffuse + ± Hypoactive
Tropical sprue + Diffuse
Celiac disease Diffuse ±, also dermatitis herpetiformis Hyperactive (increased sounds)
Hepatic causes Viral hepatitis + RUQ + +
Liver masses + + in Liver abscess RUQ ± + in sepsis
Budd-Chiari syndrome + RUQ ± - - N Laboratory findings consistent with the diagnosis of acute and fulminant BCS include: Findings on CT scan suggestive of Budd-Chiari syndrome include: Ascitic fluid examination shows:
Hemochromatosis RUQ Dull / aching + in cirrhotic patients may be in cardicmyopathy >60% TS
>240 μg/L SF
Raised LFT
Hyperglycemia
Ultrasound shows evidence of cirrhosis Extra intestinal findings:
  • hyperpigmentation
  • Diabetes mellitus
  • Arthralgia
  • Impotence in males
  • Cardiomyopathy
  • Atherosclerosis
  • Hypopituitarism
  • Hypothyroidism
  • Extrahepatic cancer
  • Prone to specific infections
Cirrhosis + RUQ +
Peritoneal causes Spontaneous bacterial peritonitis + Diffuse + in cirrhotic patients ± Hypoactive
  • Ascitic fluid PMN>250 cells/mm³
  • Culture: Positive for single organism
Ultrasound for evaluation of liver cirrhosis
Hollow Viscous Obstruction Small intestine obstruction Diffuse + ± Hyperactive then absent Leukocytosis Abdominal X ray Nausea & vomiting associated with constipation, abdominal distention
Volvulus Diffuse + Hypoactive Leukocytosis CT scan and abdominal X ray Nausea & vomiting associated with constipation, abdominal distention
Biliary colic RUQ + N Increased bilirubin and alkaline phosphatase Ultrasound Nausea & vomiting
Renal colic Flank pain N Hematuria CT scan and ultrasound Colicky abdominal pain associated with nausea & vomiting
Vascular Disorders Ischemic causes Mesenteric ischemia ± Periumbilical ± Hyperactive Leukocytosis and lactic acidosis CT scan Nausea & vomiting, normal physical examination
Acute ischemic colitis ± ± Diffuse + + Hyperactive then absent Leukocytosis CT scan Nausea & vomiting
Hemorrhagic causes Ruptured abdominal aortic aneurysm Diffuse + N Normal CT scan Unstable hemodynamics
Intra-abdominal or retroperitoneal hemorrhage Diffuse + N Anemia CT scan History of trauma
Gynaecological Causes Tubal causes Torsion of the cyst RLQ / LLQ ± ± N Increased ESR and CRP Ultrasound Sudden onset sever pain with nausea and vomiting
Acute salpingitis + ± RLQ / LLQ ± ± N Leukocytosis Pelvic ultrasound Vaginal discharge
Cyst rupture RLQ / LLQ + ± ± N Increased ESR and CRP Ultrasound Sudden onset sever pain with nausea and vomiting
Pregnancy Ruptured ectopic pregnancy RLQ / LLQ + N Positive pregnancy test Ultrasound History of missed period and vaginal bleeding
Extra-abdominal causes Pulmonary disorders Pleural empyema + ± RUQ/Epigastric N
Cardiovascular disorders Myocardial Infarction Epigastric + in cardiogenic shock N


References

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