Acid suppression medications have become A 62-yr-old woman with a long-standing history of presumed cryptogenic cirrhosis was referred for evaluation of an elevated bilirubin level. Workup showed an elevated alpha-fetoprotein level, and a mass in the liver was detected by imaging studies; this was confirmed as hepatocellular carcinoma by biopsy. Her past medical history was significant for a portocaval shunt procedure 30 yr prior; a wedge biopsy obtained at that time had been interpreted as postnecrotic cirrhosis, but upon current review, lesions of acute and chronic venous outflow obstruction consistent with Budd-Chiari syndrome were noted. This case is unusual in two aspects: the patient survived 30 yr after shunt surgery with undiagnosed Budd-Chiari syndrome; and the association of Budd-Chiari syndrome with subsequent hepatocellular carcinoma is uncommon.
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