Approach to the Critical Patient

Immediate priorities

Fulminant hepatic failure recognition

Airway and hemodynamic stabilization

Monitoring and targets

Monitoring bundle

Escalation triggers

Immediate consults

Multidisciplinary team activation

History

Presentation pattern

Temporal classification

Cardinal symptoms

Risk factor history

Acquired prothrombotic conditions

Inherited thrombophilias

Other triggers

Review of systems

Gastrointestinal symptoms

Constitutional symptoms

Hematologic symptoms

Neurologic symptoms

Pulmonary symptoms

Physical Exam

Vital signs

Hemodynamic assessment

Abdominal examination

Hepatomegaly

Ascites

Splenomegaly

Abdominal wall veins

Systemic examination

Extremity findings

Skin findings

Neurologic findings

Cardiac examination

Differential Diagnosis

Hepatic vascular mimics

Right-sided heart failure / constrictive pericarditis

Sinusoidal obstruction syndrome (SOS/VOD)

Tricuspid regurgitation

Hepatic parenchymal disease

Cirrhosis — any etiology

Acute hepatitis — viral or drug-induced

Portosinusoidal vascular disease

Vascular obstruction mimics

Portal vein thrombosis (without hepatic vein involvement)

IVC obstruction — extrinsic compression or membrane

Hepatic malignancy with venous invasion

Laboratory Tests

Hepatic function panel

Aminotransferases

Bilirubin

Albumin

Alkaline phosphatase

Coagulation studies

PT/INR

Factor V level

aPTT and fibrinogen

Hematologic evaluation

Complete blood count with differential

Peripheral blood smear

Renal and metabolic panel

Creatinine and BUN

Serum lactate

Ascitic fluid analysis

Diagnostic paracentesis

Thrombophilia workup

Molecular testing — first line

Protein-based thrombophilia testing

Additional markers

Diagnostic Tests

Scoring Systems

Rotterdam BCS Prognostic Score

BCS-TIPS Prognostic Index (BCS-PI)

West Haven Criteria — hepatic encephalopathy grading

MRI

Indications

MRI venography protocol

Characteristic findings

Pearls

CT

Indications

Protocol

Characteristic findings

Limitations

Ultrasound

Doppler ultrasound — first-line imaging

Diagnostic findings

Additional ultrasound findings

Hepatic venography

Disposition

Admission criteria

ICU-level admission

General ward admission

Transfer criteria

Transfer to tertiary liver center

Transfer timing

Discharge criteria

Outpatient management

Follow-up planning

Treatment

Anticoagulation therapy

Initial anticoagulation — LMWH preferred

Long-term anticoagulation — warfarin (VKA)

Direct oral anticoagulants (DOACs)

Portal hypertension management

Ascites management — stepwise

Variceal bleeding prophylaxis

Active variceal hemorrhage

Underlying cause treatment

Myeloproliferative neoplasms

Paroxysmal nocturnal hemoglobinuria

Antiphospholipid syndrome

Interventional procedures — stepwise approach

Step 1: Medical therapy (all patients)

Step 2: Angioplasty with or without stenting

Step 3: TIPS or DIPS

Step 4: Liver transplantation

Special Populations

Pregnancy

Epidemiology and risk

Diagnosis in pregnancy

Treatment modifications

Delivery planning

Geriatric

Epidemiology in older adults

Diagnostic considerations

Treatment modifications

Pediatrics

Epidemiology in children

Etiology in pediatric BCS

Diagnosis in children

Treatment in children

Background

Epidemiology

Incidence and prevalence

Etiology distribution

Outcomes

Pathophysiology

Mechanism of venous obstruction

Hepatic consequences of outflow obstruction

Thrombosis pathophysiology

Therapeutic Considerations

Rationale for stepwise approach

Anticoagulation rationale

TIPS mechanism in BCS

HCC surveillance rationale

Monitoring liver treatment response

Patient Discharge Instructions

copy discharge instructions

Your diagnosis and condition

Your medications

Diet and lifestyle

Follow-up appointments

Return to emergency department immediately for

References

Guidelines and key sources

ACG Clinical Guideline: Disorders of the Hepatic and Mesenteric Circulation (2020)

AASLD Practice Guidance: Vascular Liver Disorders and Portal Vein Thrombosis (2021)

Primary Budd-Chiari Syndrome — NEJM Review (2023)

Landmark studies

Budd-Chiari Syndrome: Presentation, Management, and Prognosis (2025)

Diagnostic Accuracy of Doppler Ultrasound, CT and MRI in Budd-Chiari Syndrome (2020)

Myeloproliferative Neoplasms in Budd-Chiari Syndrome — Meta-Analysis (2012)

Ultrasound Characteristics of BCS — Multicenter Analysis (2024)

Interventions in Budd-Chiari Syndrome — Updated Review (2025)