This report describes the sonographic and MR appearances of acute Budd-Chiari syndrome (BCS) in a 30-year-old woman. Current imaging techniques including duplex Doppler sonography and dynamic gadolinium-enhanced MRI were employed, and direct histopathologic correlation was made. Duplex Doppler sonography revealed a heterogeneous enlarged liver, no flow in the left and middle hepatic veins, and only trace abnormal flow in the distal-most right hepatic vein. Dynamic serial gadolinium-enhanced, spoiled gradient echo imaging demonstrated early homogeneous enhancement of an enlarged caudate lobe, as well as heterogeneously decreased enhancement of the remainder of the hepatic parenchyma. This differential enhancement pattern persisted on delayed imaging. Patent hepatic veins were not demonstrated on any sequence. Associated findings included hepatomegaly, ascites, and patent portal vasculature. These imaging findings were interpreted as consistent with acute BCS. Within 10 days, the patient underwent orthotopic liver transplantation. Histopathology demonstrated hepatic necrosis and hepatic venous thrombosis consistent with acute BCS.
 

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