Budd-Chiari syndrome in a patient with antiphospholipid syndrome: hiding in plain sight

We describe the case of a woman in her 40s on lifelong anticoagulation with warfarin due to antiphospholipid syndrome presenting with acute right upper quadrant pain. Liver tests were only slightly elevated, and non-invasive imaging such as Doppler ultrasound and contrast-enhanced CT were non-diagnostic. As suspicion for a thrombotic complication persisted, repeat CT imaging ultimately confirmed the diagnosis of Budd-Chiari syndrome (BCS), and angiography was performed allowing for effective treatment with balloon angioplasty. This case highlights both the need for a high degree of clinical suspicion for BCS in patients with prothrombotic features (even those on anticoagulation) and also the diagnostic and therapeutic potential of interventional radiology in selected cases.