The INITIAL investigation of choice in acute budd chiari syndrome is:

Doppler sonography of the liver, with sensitivity and specificity of 85% or greater, is the technique of choice for initial investigation when BCS is suspected. Massive caudate lobe enlargement causing compression of the inferior vena cava in a patient with abdominal distention and pedal edema suggests the diagnosis of: Cirrhosis with poal vein thrombosis Budd chiari syndrome Hepatocellular carcinoma Cirrhosis with poal hypeension The caudate lobe is often spared in BCS as the emissary veins drain directly into the IVC at a lower level than the involved main hepatic veins. MUST KNOW: 1. It leads to caudatelobe hyperophy. 2. The IVC may show narrowing due to compression by the enlarged caudate lobe. Ref: J Ultrasound Med 2006; 25:373-379.