Anmolpreet Gurwal

One of the most intriguing findings here is the report of a cirrhotic liver on imaging.

At this point, I would be cautious about accepting that diagnosis at face value.

It is possible that the imaging is reflecting a cirrhosis mimic or pseudocirrhosis.

But if it is truly present, what is the underlying etiology?

This would involve evaluating any family history, patient's BMI, alcohol, glycosylated hemoglobin, or any other metabolic disease.

If a cirrhosis is truly present, it can easily explain the ascites by virtue of portal hypertension.

However, there is another important possibility here that is non-cirrhotic portal hypertension.

In the setting of JAK2 positive disease, I am particularly concerned about splanchnic venous thrombosis as part of the portocinusoidal vascular disease spectrum.

we can actually revisit the anatomy because we know the liver receives its dual blood supply from the portal vein and hepatic artery, ultimately draining into the hepatic vein.

So portal vein thrombosis or splenic vein thrombosis, they represent pre-hepatic etiologies of portal hypertension and hepatic vein thrombosis, also known as Bud-Chiari syndrome, represents a post-hepatic etiology.

However, the presence of patent portal and hepatic veins on imaging makes large vessel obstruction less likely.

The most important next step is to perform a diagnostic parasyntesis, which will help us distinguish between portal hypertensive and non-portal hypertensive causes of ascites, and therefore it will guide our further management and further differential diagnosis.

Wow, amazing.

What a case this has been.

So now with the biopsy results in hand, we can finally bring everything together.

But before we interpret the biopsy, let's take a step back and briefly review how it was obtained.

a transjugular liver biopsy was performed which, unlike the percutaneous approach, accesses the liver via the internal jugular vein.

This route is particularly useful in patients with ascites or coagulopathy as it minimizes the bleeding risk by keeping any potential hemorrhage within the vascular system rather than in the peritoneal cavity.

So I can pretty much understand why the transjugular approach was taken for this patient.

So in this process basically the catheter is advanced from the internal jugular vein into the superior vena cava and then through the right atrium into the inferior vena cava and ultimately into the hepatic vein.