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From question on page 1383

The diagnosis was mediastinal tumour presenting with Budd-Chiari syndrome.

Patients may present with acquired Budd-Chiari syndrome due to sudden or gradual occlusion of the hepatic veins, the inferior vena cava (IVC), or both. On examination, the patient may be jaundiced and display lower limb oedema. Shortness of breath may also be present secondary to decreased cardiac return. Liver function test results are non-specific and may show moderately elevated bilirubin and alkaline phosphatase levels. Various factors are known to be associated with hepatic or IVC thrombosis such as trauma, medications, congenital abnormalities, and neoplasms.

Mediastinal or pulmonary tumours may rarely cause obstruction of the IVC leading to development of Budd-Chiari syndrome. In this case the mediastinal tumour was a thymic carcinoma with metastases to the pericardium that caused IVC and hepatic venous thrombosis leading to the initial presentation with Budd-Chiari syndrome (fig 2).

Figure 2

 Coronal reformatted image along the plane of the inferior vena cava (IVC) shows the mediastinal mass (arrow) causing extensive thrombus in the IVC (arrowheads) and hepatic veins (curved arrow). Note ascitis (*).

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