Young lady with abdominal pain

A 34 year old lady has never been ill. Her only medication is the oral contraceptive pill.  She is admitted with sudden onset abdominal pain.
Na 145 mmol/l
K 4.2 mmol/l
Urea 5.7 mmol/l
Creat 100 µmol/l 

Bili 42 µmol/l
ALP 257 iu/l mmol/l
AST 98 iu/l
Albumin 37 g/l
Amylase 684 iu/l

The admitting junior doctor organises a CT and an urgent Endoscopy.  The CT is reported as showing: Normal spleen, kidneys and pancreas. Distended intrahepatic veins. Portal vein enlarged at 1.2 cm with dilated collateral circulation. Caudate lobe of liver enlarged but otherwise normal liver appearances.  Small amount of ascites noted. 

WHAT WOULD YOU DO NEXT?

■ Go ahead with the OGD

You are missing it!

■ Start terlipressin

Surely you don't believe that?

■ Start an IV PPI infusion

Nonsense!

■ Refer her to the hepatologists

Yes! You know what's wrong don't you?

■ Refer her to the surgeons

She may well need a transplant in the end but ...

explanation

There is more to a high quality endoscopy service than poking a tube into a patient.  To make sure that I don't miss anything and to confirm that the endoscopy is appropriate, I always take a few minutes to 'read up' before I bring the next patient into the endoscopy room.  After all, I may well be providing the most senior clinical input since the patient was originally referred !!!  

Of course almost anything in Gastroenterology can present with abdominal pain.  In this case, the 'pattern' which you must not miss is:  1) presentation of ascites and 2) relatively normal LFT's. Of course, this is the hallmark of hepatic vein thrombosis. Missing a Budd-Chiari syndrome  (the enlarged caudate lobe is also one hell of a clue!) is supposedly one of the cardinal sins in hepatology.  Of course, the last thing this patient needs is a gastroscopy and you should immediately get in touch with your local hepatologists as this is an emergency.