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|Year : 1977 | Volume
| Issue : 1 | Page : 33-34
Partial occlusion of the entire inferior vena cava
NP Vas1, RA Bhalerao2, A Pinto2, H DaCosta3, SM Merchant1
1 Bai Jerbai Wadia Hospital for children, Parel, Bombay-40012, India
2 K. E. M. Hospital, Parel, Bombay-40012, India
3 Radiation Medical Centre, Parel, Bombay-40012, India
N P Vas
Bai Jerbai Wadia Hospital for children, Parel, Bombay-40012
Source of Support: None, Conflict of Interest: None
A patient with idiopathic partial occlusion of the entire inferior vena cava is described with results of hepatosplenic scintigraphy, radiology and necropsy.
|How to cite this article:|
Vas N P, Bhalerao R A, Pinto A, DaCosta H, Merchant S M. Partial occlusion of the entire inferior vena cava. J Postgrad Med 1977;23:33-4
| :: Introduction|| |
Idiopathic partial occlusion of the entire inferior vena cava (I.V.C.) is rare and we report. a child whose diagnosis was established antemortem and was subsequently confirmed at necropsy.
| :: Case report|| |
The patient was a 7 year old boy who came with gradual distension of the abdomen for two months. A month before the distension was noticed, he had jaundice, high fever and nausea for 5 days. On examination he was malnourished and weighed only 20 kg. in spite of considerable ascites. The liver extended 1 cm. below the right costal margin and the spleen was just palpable. Hepato-jugular reflux was doubtful; abdominal veins were not evident.
Laboratory investigations: Haemoglobin was 11 gm.% total leucocyte count was 7,800/c.mm. with 73% neutrophils and 27% lymphocytes. Erythrocyte sedimentation rate (Wintrobe) was 28 mm hour and Mantoux reaction was strongly positive. Serum transaminases and liver function tests were normal. Serum albumin was 3.76 gm, %, and total serum globulin was 2.84 gm.% with grossly normal fractions. Bleeding and clotting times were normal. Ascitic tap revealed 112 cells/c.mm and 1600 mg.% proteins. No organisms were detected or cultured from the ascitic fluid, sputum or blood.
Radio-isotope study: The child was positioned supine under the 13" detector head of a Picker Dyna Scinticamera. the heart was partially inside the visual field, superiorly. Thus, the anatomic site of the entire I.V.C. and a small portion of the right iliac vein were covered by the detector. 2 mCi 99m Tc phytate was injected into the right malleolar vein (RMV) and scintiphotos were taken at approximately 1 sec. intervals for the first 20 sees. The dynamic study was then terminated and static hepatosplenic reticuloendothelial system (RES) scintiphotos were taken after 10 mins.
In normal subjects the I.V.C. see [Figure 1 A a] on page 34a is seen as a vessel of a uniform, appreciably sized calibre; the subsequent RES scan [Figure 1A b] at 10 mins. depicts normal liver and spleen. In this patient, only a trickle of the radiopharmaceutical could pass through the I.V.C. [Figure 1B a] ; the right iliac vein appeared as a large vessel with collaterals arising from it (inferior corner). The static scintiphotos depicted uniform radio-nucleide concentration in a single (uniform) RES mass [Figure 1 B b] ; the spleen was grossly normal in size as seen in the right lateral view [Figure 1 B c] but it concentrated more radio-colloid than normal.
The hepato-biliary system was evaluated by injecting 2 mCi 99m Tc pyridoxylidene glutamate intravenously. At 1 hour [Figure 1C a] some radioactivity was still in the heart, but the liver had concentrated well; the 3 hour scintiphoto [Figure 1C b] depicted considerable excretion into the intestines. Thus, there was no obstruction in the biliary system.
Repeat study 2 months following intensive anti-tubercular therapy failed to reveal any change.
Radiocontrast study: In view of the radio-nucleide scintigraphic findings, a lack of change following anti-tubercular treatment and an increasing need for paracentesis, the child was transferred to the surgical unit where a classical radiocontrast inferior vena cavogram [Figure 2 A] confirmed partial occlusion of the I.V.C. with collateral circulation. A hepatogram [Figure 2 B] showed retrograde filling of the portal vein instead of a normal entry of the material into the I.V.C.
Necropsy: The child expired suddenly while awaiting a venous graft. Necropsy revealed the IV.C. to be a fibrosed cord histologically composed of fibroblasts infiltrated with a few small capillaries. The hepatic veins and their ostia were unaffected. The irregular liver showed marked central venous congestion [Figure 2 C] as did all other organs which normally drain into the I.V.C. No etiology was discernible for the considerably narrowed I.V.C. lumen. No other vessel revealed any occlusive changes and the peritoneum was normal although considerable free fluid was present.
| :: Discussion|| |
The child presented as a case of massive ascites requiring daily paracentesis. His liver function tests were normal except for a low albumin level. Observation of radiopharmaceutical bolus under a scinticamera revealed the diagnosis of partial occlusion of the entire I.V.C. without resorting to any invasive procedure; this diagnosis was not suspected but nucleovenography was done as a routine procedure during hepatosplenic scintigraphy. Budd Chiari syndrome is not rare and the I.V.C. abnormalcy is secondary to a hepatic or renal pathology. , In this instance however, no other primary cause was determined; there were no blood clots or malignant cells in the lumen of the vessel and no other artery or vein was similarly diseased. Deterioration in the child's condition spelt progression of the lesion, yet no signs of infection, inflammation or collagen deposition were seen at necropsy. Furthermore, the entire vessel was uniformly affected.
| :: References|| |
|1.||Bras, G.: Aspects of hepatic vascular disease in "Liver" 1973, p. 406. Ed. E. Gall and F. Mostoffi. Williams & Wilkins, Baltimore. |
|2.||Sherlock, S.: Diseases of the liver and biliary system. 1968, p. 245. Ed. S. Sherlock, Blackwell Sc., London. |
[Figure 1 A a], [Figure 1A b], [Figure 1B a], [Figure 1 B b], [Figure 1 B c], [Figure 1C a], [Figure 1C b], [Figure 2 A], [Figure 2 B], [Figure 2 C]