BCS is the manifestation of hepatic
venous outflow obstruction
 Hepatic venous obstruction can occur
at the level of the IVC or the hepatic
veins
 BCS is a rare and life threatening
condition if not treated promptly

 HCC
 Renal
Carcinoma
 Pregnancy
 Congenital Abnormalities
 Coagulation Abnormalities
› Polycythemia
› Rubra vera
› Chronic leukemia
• In order to adequately
visualise the middle and left
hepatic veins – scan
the liver in a transverse cross
section at the level of the
xiphoid process
and
angle the transducer
cranially
• The right hepatic vein can
be evaluated from a right
intercostal approach
INTERCOSTAL SCAN PLANE From
Ultrasoundpedia, 2014
From Ultrasoundpedia, 2014
Duplex ultrasound of the normal
blood flow in the middle hepatic
vein. Flow is phasic in response to
both the cardiac and respiratory
cycles
From ImageArcade, 2014
B-mode image of the hepatic
veins. Blood flows from the
hepatic veins into the IVC
immediately prior to the Right
Atrium
Chaubal et al 2006. J Ultrasound Med 25:1
373-379
White arrows represent
thrombus within the left and
middle hepatic veins whilst
the thin arrows shows
narrowing stenosis of the
distal MHV as it drains into
the IVC
Chaubal et al 2006. J Ultrasound Med 25:1
373-379
White arrow shows intrahepatic collaterals with a
enlarged caudate lobe
(asterisk)
Bargallo et al 2006. Am J Retrogenol; 187:W33-W42
Normal flow is seen in
the middle hepatic
vein. However, the right
hepatic vein shows
abnormal, inverted flow
Kandpal et al 2008. RadioGraphics; 28: 669-689
Loss of cardiac
pulsation is indicated by
Duplex ultrasound
showing reversed flow
in the IVC
There may be underestimation of the
presence of thrombus and the
characteristic ‘membranous webs’ may
be inconclusive in cirrhotic patients with
hepatic veins that are difficult to image
 BCS can be hard to distinguish from
Hepatic veno-occlusive disease
(progressive occlusion of hepatic
venules).
 Ultrasound is highly operator dependent







Using real time scanning, radiologists can evaluate the IVC
and hepatic veins non invasively
Using Duplex and Colour Ultrasound, the presence and
direction of evaluation of hepatic venous flow can occur
in patients with suspected BCS.
Associated reversal of flow in portal vein can also be
assessed.
B-mode imaging can be used to draw conclusions on
missing compressed or otherwise abnormal hepatic veins
and IVC.
The presence of epigastric collaterals can be readily
assessed
Ultrasound imaging is an important tool in BCS affecting
patient management from diagnosis - follow up after
treatment!!

Traditionally
› Surgical porto-systemic shunting
› Liver transplant (for patients with end stage
liver failure

More recently
› Recanalization of stenosed segments of
hepatic vein/IVC
› TIPS – Transjugular Intrahepatic Portosystemic
shunts
Image showing TIPS – an
artificial connection is
between the hepatic vein
and portal vein is made via
a stent in order to reduce
portal venous pressure.
From BayCare Clinic 2014
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2.
3.
4.
5.
6.
7.
8.
9.
10.
11.
"Budd–Chiari Syndrome." Wikipedia. July 1, 2014. Accessed October 20, 2014.
http://en.wikipedia.org/wiki/Budd–Chiari_syndrome.
"Gallery For Hepatic Veins Ultrasound." Gallery For Hepatic Veins Ultrasound. January 1, 2014.
Accessed October 30, 2014.
"ULTRASOUND OF THE LIVER - Normal." Ultrasoundpaedia. January 1, 2013. Accessed October 13,
2014.
Scoutt, Leslie. "Ultrasound Evaluation of Portal Hypertension." SONOWORLD. January 1, 2013.
Accessed October 30, 2014.
Kamath, Patrick S. "Budd-Chiari Syndrome: Radiologic Findings." Liver Transplantation 12, no. 1 (2006):
S21-22.
Rumack, Carol M.Diagnostic Ultrasound. 3rd ed. St. Louis: Elsevier Mosby, 2005.
Bargallo, X., Rosa Gilabert, Carlos Nicolau, Juan Carlos García-Pagán, Juan Ayuso, and Concepció
Bru. "Sonography of Budd-Chiari Syndrome." American Journal of Roentgenology187, no. 1 (2006):
W33-41
Chaubal, Nitin, Vijay Hanchate, Manjir Dighe, Hemangini Thakkar, Hemante Deshmukh, and
Krantikumar Rathod. "Sonography in Budd-Chiari Syndrome." J Ultrasound Med 25, no. 1 (2006): 37379.
Knipe, Henry, and Frank Gaillard. "Budd-Chiari Syndrome." Radiopaedia Blog RSS. January 1, 2014.
Accessed October 17, 2014. http://radiopaedia.org/articles/budd-chiari-syndrome-1.
Haffar, Samir. "Doppler Ultrasound of Budd Chiari Syndrome & SOS." Doppler Ultrasound of Budd
Chiari Syndrome & SOS. June 27, 2013. Accessed October 15, 2014.
Mukund, Amar, and Shivanand Gamanagatti. "Imaging and Interventions in Budd-Chiari
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