• Vol. 35 No. 7, 504–507
  • 15 July 2006

A Bolt Out of the Blue: A Case of Unexpected Acute Liver Failure



Introduction: We describe an unusual case of acute hepatitis leading rapidly to acute liver failure.

Clinical Picture: Our patient had known chronic hepatitis B with a regenerating nodule confirmed on imaging and histology. He was admitted initially for abdominal discomfort after a trip to China, and investigations showed acute hepatitis with alanine transaminase (ALT) and aspartate transaminase (AST) at 678 and 557 U/L, respectively. Initial differential diagnoses were acute exacerbations of chronic hepatitis B, and viral hepatitis A or E. However, acute Budd-Chiari syndrome was diagnosed on computed tomography (CT) scan of the abdomen, which showed extensive thrombosis of the hepatic vein, all the intrahepatic branches, inferior vena cava, up to the right atrium.

Treatment: Due to the extensive nature of the thrombus, radiological or surgical intervention could not be performed.

Outcome: The patient was managed conservatively but progressed rapidly and died of acute liver failure 16 days after presentation.

Conclusion: Our case highlights the rapidity of progression of acute Budd-Chiari syndrome. Diagnosis and management of Budd-Chiari syndrome are discussed.

Acute hepatitis could result from viral, autoimmune or drug-reaction causes, among others. In areas endemic with hepatitis B, acute exacerbations of chronic hepatitis B (CHB) are the commonest cause. Hence, in Singapore where 4% of the population are hepatitis B carriers, when faced with acute hepatitis in a patient with known CHB, hepatologists often consider acute exacerbations of CHB as the most likely aetiology, which may lead to a delay in diagnosis in cases not caused by CHB.

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