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nbme19/Block 3/Question#11 (4.4 difficulty score)
A 48-year-old man comes to the physician for ...
Budd-Chiari syndrome๐Ÿ”,๐Ÿ“บ
tags: budd_chiari 

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submitted by shieldmaiden(18),

How do the h/o renal cell carcinoma and removal of one kidney/adrenal correlate with occlusion of the hepatic vein?

an_improved_me  looks like RCC may extend into the IVC with tumor thrombus leading to hepatic vein occlusion https://www.ncbi.nlm.nih.gov/pmc/articles/PMC3193735/ +2  
an_improved_me  In general though, i don't think you need to know that... I think the important things are that: tells you there is widening of hepatic venules (which one can imagine is due to increased pressure) tells you that hepatic wedge pressure (estimate of portal pressure) is 30; portal pressure should be less than 5. therefore, elevated portal pressure in the absence of RA pressure indicates obstruction before the heart (in this case, budd chiari). Compare that to cardiac cirrhosis, which would have increased RA pressures AND increased portal venous pressures. +1  
an_improved_me  Shit, and finally, since there are only mild increases in billi, AlkPhos, AST/ALT, i think that rules out cirrhosis. +1  
an_improved_me  Add the fact that he doesn't have risk factors for cirrhosis (no drinking, smoking cigs, [would have loved to see a negative serology panel...], i think that also brings cirrhosis further down on your DDx +1  
an_improved_me  Add the fact that he doesn't have risk factors for cirrhosis (no drinking, smoking cigs, [would have loved to see a negative serology panel...], i think that also brings cirrhosis further down on your DDx +1  
an1  I had it down to the 2 options too. and I went with hepatic venues because I know that's related to BC more than it is to cirrhosis per say. But another way to approach this could be that due to renal removal, he may be taking exogenous EPO, which can lead to thrombosis (often seen with poly vera; which also happen to be ht eMCC of BC) +