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Internal Medicine

Congestive hepatopathy “Nutmeg liver”

Nutmeg is the seed or ground spice of several species of the genus Myristica. Myristica fragrans (fragrant nutmeg or true nutmeg) is a dark-leaved evergreen tree cultivated for two spices derived from its fruit: nutmeg and mace.

Congestive hepatopathy, also known as nutmeg liver and chronic passive congestion of the liver, is liver dysfunction due to venous congestion, usually due to congestive heart failure.

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The gross pathological appearance of a liver affected by chronic passive congestion is “speckled” like a grated nutmeg kernel; the dark spots represent the dilated and congested hepatic venules and small hepatic veins. The paler areas are unaffected surrounding liver tissue.

Clinical features

  • Sense of fullness and tenderness in the right hypochondriac region
  • Gastrointestinal catarrh
  • Vomiting of blood
  • Jaundice
    • Light or clay-colored stool
    • Bile coloured urine
  • Ascites, followed later by generalised oedema
    • Due to portal obstruction
  • Enlarged and tender liver

Complications

  • Severe and longstanding hepatic congestion,
    • Fibrosis (cardiac cirrhosis)

Diagnosis

Investigations

  • Electrocardiogram (EKG)
  • Diagnostic paracentesis

Imaging

  • RUQ-USG + Doppler studies (of portal vein and hepatic veins & artery)
  • Echocardiograph (ECG)
  • CT-scan
    • Dilatation of the IVC and hepatic veins
    • Retrograde hepatic venous opacification shortly after IV contrast injection
    • Heterogeneous hepatic enhancement due to stagnant blood flow
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CT appearance of liver in congestive hepatopathy, sometimes referred to as a nutmeg liver. Due to congestion, contrast does not flow through the liver in a normal manner. Axial and coronal images in the portal venous phase. | Hellerhoff – CC BY-SA 3.0, https://commons.wikimedia.org/w/index.php?curid=47391719

Histopathology

  • Perisinusoidal fibrosis
  • Hepatic venule dilation
  • Dilation of the sinusoids in zone III (centrilobular)
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Congestive hepathopathy is characterized by: Perisinusoidal fibrosis, Hepatic venule dilation, and Dilation of the sinusoids in zone III (centrilobular). | Nephron – CC BY-SA 3.0, https://commons.wikimedia.org/w/index.php?curid=7765961

Management

Treatment of underlying cause

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