Blood investigations

Hypersplenism may result in anaemia and reduced WBC and platelet count. Plasma concentrations of procoagulant and anticoagulant proteins may be reduced in portal venous thrombosis or Budd-Chiari syndrome. Biochemical liver function tests are abnormal in cirrhosis, but are rarely deranged in portal venous occlusion. Serum albumin levels are depleted in acute variceal bleed.

 Ultrasound scan of abdomen

Large collateral veins, portal cavernoma and splenomegaly, which are the features of portal hypertension, may be identified on sonography of abdomen. Doppler studies provide the information about the direction, velocity and waveform characteristics of portal blood flow. In cirrhosis of liver, the maximum velocity of the blood flow in the main portal trunk is inversely correlated with the severity of the liver disease. In Budd-Chiari syndrome, Doppler sonography of the hepatic veins and the inferior vena cava can be conclusive. Ascitis which is a notable feature of Budd-Chiari syndrome and of cirrhosis of liver can be definitely identified and quantified on ultrasonography.

 Upper and lower gastro-intestinal endoscopy

This modality is useful in the diagnosis and treatment of varices of the oesophagus, stomach, the proximal duodenum and the ano-rectal area. However, it may be safer and easier of the procedure is performed under a general anesthesia. Various grading systems are used in the assessment of oesophageal varices. Smaller varices are bluish with a relatively thick mucosal covering while the larger ones may have signs of recent or impending bleed like 'cherry red spots' or 'varices on varices'. Portal congestive gastropathy is characterized by mucosal hyperaemia with dilated submucosal veins.

 CT angiography and MRI scan

The above modalities are increasingly used in the diagnosis of Budd-Chiari syndrome and to identify liver lesions associated with portal hypertension like focal nodular regenerative hyperplasia. MR angiography is recently used as a non-invasive alternative to conventional angiography to delineate porto-mesenteric venous anatomy.

 Angiography

Inferior vena cavography with pressure measurements is valuable in patients with Budd-Chiari syndrome in whom hepatic venography can be used to assess hepatic venous patency. Balloon dilatation can be undertaken of inferior vena caval membrane or short segment narrowing of the hepatic veins, which can prove therapeutic.