A 32-year-old woman presents with acute onset abdominal pain, ascites, and tender hepatomegaly. She has been taking oral contraceptive pills for 3 years. Ultrasound shows hepatic vein thrombosis with caudate lobe hypertrophy. Which is the most important initial management?

• A Emergency portocaval shunt
• B Transjugular intrahepatic vein angioplasty
• C Liver transplantation
• D Anticoagulation with heparin ✓

Explanation

Budd-Chiari syndrome is hepatic venous outflow obstruction, commonly associated with myeloproliferative disorders, oral contraceptives, and hypercoagulable states. Anticoagulation is the cornerstone of initial management regardless of whether an underlying cause is identified. Interventions like TIPS or angioplasty are reserved for patients who fail medical therapy.

Reference: Harrison's Principles of Internal Medicine, 21st ed.

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