Budd Chiari syndrome presenting with hepatic transient mosaic enhancement pattern and treated with early transjugular intrahepatic portosystemic shunt

Budd Chiari syndrome (BCS) can present with ascites and with the so-called hepatic mosaic enhancement pattern (MEP) on CT and MR imaging, as well as other different diseases. However, no previously cases of transient MEP and BCS were reported. Transjugular intrahepatic portosystemic shunt (TIPS) is an established interventional treatment of BCS, whose timing is a debated issue. We report a case of BCS presenting with ascites and transient MEP and treated with early TIPS. We report the case of a 73-year-old man who presented with ascites and MEP on CT imaging. Anticoagulant therapy resulted in disappearance of MEP, despite persistence of ascites. However, liver biopsy was performed confirming a picture of BCS. Despite clinical albeit suboptimal response to medical therapy, TIPS was performed. Subsequently, ascites disappeared and the clinical outcome was favourable after 30 months. Transient hepatic MEP on CT imaging may be indicative of BCS. Furthermore, early interventional treatment for of BCS could challenge the step-wise strategy.