Answer

From question on page 53

Magnetic resonance (MRI) axial and coronal T2 weighted images (fig 1A, B) showed ascites, extensive liver and kidney cysts, and narrowing of the cava vein. MRI gadolinium enhanced T1 weighted image (fig 1C) confirmed the cystic nature of the liver lesions without enhancement. Sagittal plane reconstruction of the image (fig 1D) demonstrated severe compression of the retrohepatic cava vein (arrow) that was confirmed by the cavogram (fig 1E), also depicting large paravertebral collateral veins. Autosomal dominant polycystic kidney/liver disease causing compression of the vena cava was diagnosed.

A Palmaz stent was placed in the narrowed vein. In the following days, daily urine volume increased and, at discharge, furosemide 75 mg/daily was prescribed. The patient regained body weight and a good quality of life; after 66 months of follow up she remains well and ultrasonography shows only minimal ascites.

Caval hypertension may have a relevant role in determining ascites accumulation in patients with polycystic liver and therefore in this setting inferior vena cava patency should be accurately evaluated. MRI is a useful diagnostic tool and, if stenosis is showed, caval stenting should be the first therapeutic procedure.