title: A bolt out of the blue: a case of unexpected acute liver failure.
abstract: BACKGROUND
  We describe an unusual case of acute hepatitis leading rapidly to acute liver failure.
  
  
  METHODS
  Our patient had known chronic hepatitis B with a regenerating nodule confirmed on imaging and histology. He was admitted initially for abdominal discomfort after a trip to China, and investigations showed acute hepatitis with alanine transaminase (ALT) and aspartate transaminase (AST) at 678 and 557 U/L, respectively. Initial differential diagnoses were acute exacerbations of chronic hepatitis B, and viral hepatitis A or E. However, acute Budd- Chiari syndrome was diagnosed on computed tomography (CT) scan of the abdomen, which showed extensive thrombosis of the hepatic vein, all the intrahepatic branches, inferior vena cava, up to the right atrium.
  
  
  METHODS
  Due to the extensive nature of the thrombus, radiological or surgical intervention could not be performed.
  
  
  RESULTS
  The patient was managed conservatively but progressed rapidly and died of acute liver failure 16 days after presentation.
  
  
  CONCLUSIONS
  Our case highlights the rapidity of progression of acute Budd-Chiari syndrome. Diagnosis and management of Budd-Chiari syndrome are discussed.
authors.affiliation: Department of Gastroenterology and Hepatology National University Hospital, Singapore.
authors.forename: Reuben K M
authors.initials: RK
authors.lastname: Wong
authors.forename: Chun-Tao
authors.initials: CT
authors.lastname: Wai
mesh_terms: D006502:Budd-Chiari Syndrome / Q000150:complications* / Q000175:diagnosis / Q000000981:diagnostic imaging; D003937:Diagnosis, Differential; D017809:Fatal Outcome; D006503:Hepatic Veins / Q000000981:diagnostic imaging; D019694:Hepatitis B, Chronic / Q000175:diagnosis; D006801:Humans; D008099:Liver / Q000000981:diagnostic imaging; D017114:Liver Failure, Acute / Q000209:etiology*; D008297:Male; D008875:Middle Aged; D014057:Tomography, X-Ray Computed; D014682:Vena Cava, Inferior / Q000000981:diagnostic imaging