Differentials
Budd-Chiari syndrome
SIGNS / SYMPTOMS
Abdominal pain, diarrhoea, and progressively worsening ascites.
INVESTIGATIONS
Doppler ultrasound and abdominal CT: absence of hepatic vein filling.
Abdominal CT: rapid contrast clearing of caudate lobe.
Portal vein thrombosis
SIGNS / SYMPTOMS
Signs and symptoms of the underlying cause such as acute pancreatitis (severe upper abdominal pain radiating through to the back, vomiting, absent bowel sounds, pyrexia, hypovolaemic shock, skin discoloration periumbilically [Cullen's sign] and in the flanks [Grey Turner's sign]), ascending cholangitis (pyrexia, malaise, rigors, right upper quadrant pain, jaundice, dark urine, and pale stools), or abdominal sepsis (pyrexia, abdominal pain, signs of peritonism).
INVESTIGATIONS
Magnetic resonance (indirect) or direct angiography: normal hepatic venous pressure gradient (measure of portal pressure).
Doppler ultrasound and abdominal CT: portal vein filling defect, absence of flow in the portal vein.
Splenic vein thrombosis
SIGNS / SYMPTOMS
Signs and symptoms of pancreatitis: severe upper abdominal pain radiating through to the back, vomiting, absent bowel sounds, pyrexia, hypovolaemic shock, and skin discoloration periumbilically (Cullen's sign) and in the flanks (Grey Turner's sign) in acute pancreatitis; non-specific abdominal pain exacerbated by eating, diarrhoea, steatorrhoea, weight loss, and mild pyrexia in chronic pancreatitis.
INVESTIGATIONS
Abdominal ultrasound and CT: evidence of splenic vein thrombosis.
Magnetic resonance (indirect) or direct angiography: normal hepatic venous pressure gradient (measure of portal pressure).
Nodular regenerative hyperplasia
SIGNS / SYMPTOMS
No differentiating signs and symptoms.
INVESTIGATIONS
Liver biopsy: small regenerative nodules with minimal or no fibrosis on reticulin staining.
Idiopathic portal hypertension (hepatoportal sclerosis)
SIGNS / SYMPTOMS
No differentiating signs and symptoms.
INVESTIGATIONS
Liver biopsy: no evidence of cirrhosis.
Constrictive pericarditis
SIGNS / SYMPTOMS
Raised jugular venous pressure, tachycardia, and atrial fibrillation.
Heart sounds: quiet, third heart sound (ventricular knock) present.
INVESTIGATIONS
ECG: tachycardia, atrial fibrillation, low-voltage QRS complexes, T-wave abnormalities.
Doppler ultrasound: ventricular filling abnormalities.
Inferior vena cava (IVC) obstruction
SIGNS / SYMPTOMS
Signs and symptoms of renal cell carcinoma: classic triad of haematuria, flank pain, and flank/abdominal mass with weight loss and hypertension.
INVESTIGATIONS
Abdominal ultrasound and CT: evidence of IVC obstruction.
Schistosomiasis
SIGNS / SYMPTOMS
History of travel to endemic areas.
Constitutional symptoms of febrile illness: malaise, rigors, sweating, weight loss, anorexia, vomiting, diarrhoea, headache, muscular aches and weakness, and abdominal pain.
Signs of febrile illness: urticarial rash, pyrexia, and lymphadenopathy.
INVESTIGATIONS
Magnetic resonance (indirect) or direct angiography: normal hepatic venous pressure gradient (measure of portal pressure).
Sarcoidosis
SIGNS / SYMPTOMS
Lung involvement: dry cough and dyspnoea.
Skin involvement: altered pigmentation (hypo- or hyperpigmented); maculopapular skin lesions on face, back, and extremities; and erythema nodosum on legs.
Eye involvement: anterior or posterior uveitis, dry eyes (sicca), and glaucoma.
INVESTIGATIONS
Chest x-ray findings are dependent on the stage of disease progression: hilar lymphadenopathy, diffuse reticulonodular shadowing (parenchymal disease), and upper lobe fibrosis.
Liver biopsy: non-necrotising/caseating granulomas.
Vitamin A intoxication, arsenic, and vinyl chloride toxicity
SIGNS / SYMPTOMS
No differentiating signs and symptoms.
INVESTIGATIONS
History generally reveals exposure.
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