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Abdominal discomfort and abnormal liver function

BMJ 2012; 344 doi: (Published 12 June 2012) Cite this as: BMJ 2012;344:e2096
  1. Shaun Quigley, specialty registrar,
  2. Jonathan Colledge, specialty registrar,
  3. Shilpa Patel, specialty registrar,
  4. Wade Gayed, specialty registrar
  1. 1Clinical Radiology, St Bartholomew’s and the Royal London, London E1 1BB, UK
  1. Correspondence to: shaun.quigley{at}

A 79 year old man with a history of heart disease presented to the emergency department with chest pain and abdominal discomfort localised to the right upper quadrant. On examination, he had bilateral pitting oedema to the level of the thighs, scrotal oedema, and sacral oedema. He had a systolic murmur on auscultation, with normal breath sounds and no added sounds. Routine haematology and renal profile were within normal limits, although liver function tests showed bilirubin 18 μmol/L (reference range 3-21), aspartate transaminase 37 IU/L (15-40), alanine transaminase 89 IU/L (10-40), alkaline phosphatase 553 IU/L (30-126), and γ-glutamyltranspeptidase 681 IU/L (12-58). He underwent computed tomography pulmonary angiography (CTPA) (fig 1), which excluded a pulmonary embolus. An abdominal ultrasound to investigate his abnormal liver function showed dilated hepatic veins, a dilated inferior vena cava, ascites, and the presence of biphasic pulsatile portal venous flow.

Fig 1 Computed tomography pulmonary angiography: (A) coronal view and (B) axial view


  • 1 What are the relevant findings on CTPA?

  • 2 What is the mechanism behind these appearances?

  • 3 How can the liver biochemistry derangement be explained?

  • 4 How is this condition managed?


1 What are the relevant findings on CTPA?

Short answer

The computed tomography pulmonary angiogram shows cardiomegaly and dense contrast within dilated hepatic veins and ascites (fig 2).

Fig 2 Computed tomography pulmonary angiogram showing dilated inferior vena cava (arrows) and hepatic veins …

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