Pain Management of Budd Chiari Syndrome in the Primary Care Setting: A Case Study

Introduction: Budd Chiari Syndrome (BCS) is a very rare disease affecting approximately 1 in 100,000 people in the general population.  It is caused by an obstruction of the hepatic veins leading to blood backing up in the liver. Treatment options to improve hepatic blood flow and relieve ascites are well documented. However, there are no established guidelines or treatment preferences for pain associated with BCS while patients are awaiting other treatment options.  Case: A 22-year-old African American female was diagnosed with Budd Chiari Syndrome.  The initial attempt at a transjugular intrahepatic portosystemic shunt (TIPS) procedure failed.  While awaiting a second attempt at the procedure, the patient presented to her primary care provider complaining of abdominal and right upper quadrant pain.  Treatment guidelines were searched for acute pain management options; however, no BCS pain management guidelines exist. Discussion: Individuals with BCS often present with abdominal pain, however, no guidelines outlining analgesic options in BCS exists.  Acetaminophen, NSAIDs, and opioids are commonly used prescription medications for moderate to severe pain.  Acetaminophen use was not considered due to acute liver injury and portal venous thrombosis.  Anticoagulation with apixaban prevented concurrent use with NSAIDs.  Opioid medications combined with acetaminophen were excluded to minimize exacerbating the liver injury.  Tramadol 25 mg was chosen due to its lower abuse profile than other opioid analgesics, and was initiated for pain management. Conclusion: The patient reported adequate pain control with tramadol, tolerated the medication with no complications, and underwent a successful TIPS procedure one month later.  Abdominal pain is a common symptom of BCS and needs to be effectively managed.  Guidelines on treating pain associated with BCS in the outpatient setting would improve quality of life for patients and provide guidance to primary care providers requiring direction on how to address pain associated with Budd Chiari Syndrome safely and adequately.