Hepatic veno-occlusive disease Diagnosis and management Clinical presentation Suspect VOD in patients in whom liver disease occurs in the context of prior HSCT, chemotherapy for cancer, or immunosuppression for solid organ transplantation or IBD. B Ultrasound Q Does the patient have suspected VOD? No Consider alternative diagnoses. Yes Obtain an abdominal ultrasound in patients with suspected VOD, to assist in the exclusion of other disease. B Liver biopsy BCSH Q Does the diagnosis of VOD remain unclear after initial investigations? Yes Obtain a transjugular liver biopsy for patients in whom the diagnosis of VOD is unclear, and there is a need to exclude other diagnoses. B No Diagnostic criteria Use the modified Seattle or Baltimore criteria to establish the diagnosis of VOD. A Baltimore criteria for diagnosis of veno-occlusive disease Serum bilirubin > 34.2 mcmol/L (2 mg/dL) within 21 days of transplant Hepatomegaly Ascites Weight gain (> 5% from pre transplant weight) Meets criteria for veno-occlusive disease Indications for specialist referral Obtain early consultation with critical care and hepatology specialists in patients with VOD, and consider other treatment options including TIPS or liver transplantation. B Supportive care Provide supportive care for the treatment of complications of established VOD. B Fluid balance Ensure judicious fluid balance management in patients with VOD. B Defibrotide Administer defibrotide for the treatment of VOD in adults and children. B Methylprednisolone Consider administering methylprednisolone for the treatment of VOD, while taking into account the potential risks of infection. C