Question 3.4

The following data refer to a 34-year-old male admitted to ICU twenty days after an allogeneic stem cell transplant for acute myeloid leukaemia. Over the last few days he has been complaining of right upper quadrant abdominal pain, and observed to have gained several kilograms in weight.

Venous Biochemistry


Patient Value

Adult Normal Range


142 mmol/L

135 – 145


4.8 mmol/L*

3.5 – 4.5


97 mmol/L

95 – 105


22 mmol/L

22 – 26


11.2 mmol/L*

2.9 – 8.2


134 μmol/L*

70 – 120


2.13 mmol/L

2.10 – 2.55


1.21 mmol/L

0.65 – 1.45

Total bilirubin

342 μmol/L*

0 – 25

Aspartate aminotransferase (AST)

175 U/L*

< 40

Gamma glutamyl transferase (GGT)

123 U/L*

< 40

Alanine aminotransferase (ALT)

87 U/L*

< 40

  1. Give the most likely diagnosis. (10% marks)
  1. What are the characteristic findings on liver ultrasound scan? (10% marks)

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College answer

a) Veno-occlusive disease of the liver (sinusoidal obstruction syndrome)

b) ascites and reversal of portal vein flow. (2 marks)


The stem gives us everything needed to make the diagnosis here. The biochemical abnormalities are:

  • A kidney injury
  • Massively raised bilirubin
  • Relatively trivial elevation of liver enzymes

The combination of these findings with a recent history of BMT suggests strongly that veno-occlusive disease has developed. Both the Seattle and Baltimore criteria need a recent BMT, raised bilirubin and weight gain:

Seattle criteria:

  • Two or more of the following:
    • Bilirubin > 34mmol/L
    • Hepatomegaly
    • RUQ pain
    • Weight gain >2%
  • Within 20 days of BMT

Baltimore criteria:

  • Bilirubin > 34mmol/L,
    AND two or more of the following:
    • Hepatomegaly
    • Ascites
    • Weight gain >5%
  • Within 21 days of BMT

Diagnosis does not require ultrasound, but it is usually ordered in this context. The BCSH/BSBMT guidelines (2013) concluded that "the main role of ultrasound is to exclude the presence of other diagnoses" because the ultrasound findings which are usually associated with VOD are insufficiently sensitive and specific. In any case, here they are:

  • Ultrasound-confirmed ascites
  • Ultrasound-confirmed hepatomegaly
  • Splenomegaly
  • Attenuated or reversed portal venous flow
  • Thickened gallbladder wall
  • Ultrasound evidence of increasing hepatic artery  vascular resistance (there is a "hepatic artery vascular resistance index",  which is helpful in the diagnosis if it is greater than 0.75.)


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