Omar Shaltout: When Hematology Meets Gastroenterology in the ICU
Omar Shaltout, ICU Resident at Elkheer Hospital, shared on LinkedIn:
”When Hematology Meets Gastroenterology in the ICU:
A Catchy Case of Budd–Chiari Syndrome With Factor V Leiden Complicated by HRS
A 42-year-old female was admitted in a critical condition with progressive abdominal distension, hypotension, and worsening renal function.
Initial assessment showed a picture of advanced portal hypertension with tense ascites.
Ascitic fluid analysis revealed a high SAAG, confirming a portal hypertensive process.
Renal parameters were already deteriorating, raising early concern for hepatorenal physiology.
Imaging became the turning point.
Abdominal ultrasound and subsequent MRV confirmed acute thrombosis of all three hepatic veins, establishing the diagnosis of Budd–Chiari Syndrome.
The key clinical question was not the diagnosis itself, but the cause.
A comprehensive thrombophilia workup revealed a Factor V Leiden mutation (heterozygous), while secondary causes such as antiphospholipid syndrome and myeloproliferative disorders were excluded.
This finding explained the extensive hepatic venous thrombosis and reframed the case as a hematology-driven GI emergency.
Despite supportive management, the patient progressed into hepatorenal syndrome, with:
- Rapidly rising creatinine (peaking at 4.8 mg/dL)
- Severe hyponatremia
- Hypotension and metabolic derangement
Management became a delicate balance between:
- The need for lifelong anticoagulation due to inherited thrombophilia
- And the presence of significant liver-related coagulopathy and portal hypertension
This case highlighted how Budd–Chiari syndrome is never purely a hepatic disease.
It sits at the intersection of hematology, gastroenterology, nephrology, and critical care, where early recognition and timely escalation can be lifesaving.
Given the severity of portal hypertension and progressive HRS, urgent TIPS consideration with early liver transplant evaluation was recommended.”
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