Nutmeg Liver

NUTMEG LIVER
Guided by : Dr. Paresh Sir

Dr. Charmi Mam
Made by :
Himja Patel, Keshvi Patel, Man Patel,
Dhavani Patel, Keli Patel, Jeel Patel
Chronic venous congestion
 The dilation of veins and capillaries due to impaired venous drainage
results in passive hyperaemia or venous congestion, commonly
referred to as a congestion.
 Chronic congestion is more commonly called as chronic venous
congestion (CVC).
 Two types of congestion are there :
1. Local venous congestion – results from obstruction to the venous

outflow from an organ or part of the body.
 Eg ; Cirrhosis of liver.
2. Systemic venous congestion – is engorgement of systemic veins.

Usually the fluid accumulates upstream to the specific chamber of the
heart which is initially affected.
 E.g. ; left sided and right sided heart failure.
Schematic representation of mechanisms involved in chronic venous congestion of
different organs.
NUTMEG LIVER
 Nutmeg liver is the pathological appearance of the liver caused
by chronic passive congestion of the liver secondary to right
heart failure.
 Mottled appearance of the liver as a result of hepatic venous
congestion.
 It is named after the cut appearance of the nutmeg seed (an
aromatic seed of a spice tree that grows in India ,used in
cooking as spice for giving flavors).
Etiology :-
Most common cause is right heart failure. Other causes include constructive
pericarditis, pulmonary hypertension, congenital heart diseases.
 Pathophysiology :-
Congestion occurs due to three main mechanisms :-
1) Decreased hepatic blood flow
2) Decreased arterial oxygen saturation
3) Increased hepatic venous pressures
Elevated pressure in the hepatic veins and sinusoids may lead to
decreased portal venous inflow . Increased hepatic venous
pressure also causes sinusoidal congestion. This results into
dilation of sinusoidal opening which causes exudation of protiens
and fluid in the perisinusoidal space. Hence there will be
accumulation of the exudate in the space which inturn impairs
diffusion of oxygen and nutrients to hepatocytes. Decreased portal
flow may increase susceptibility to injury. This whole procedure
may lead to the hepatic congestion i.e. congestion of liver which is
termed as NUTMEG LIVER.
 Gross pathology :-
The is enlarged and tender and the capsule is tense. Cut
surface shows characteristic nutmeg appearance due to red
and yellow mottled appearance corresponding to congested
center of lobules and fatty peripheral zone respectively.
 Microscopically :-
 It is stained by H&E stain.
 Passive congestion of the liver is reflected by sinusoidal dilated,
congestion and hepatocyte atrophy most prominent in zone 3.
 The central veins are distended and filled with blood.
 The extent of necrosis, inflammation and dilation has been
correlated with right atrial and hepatic pressures, although
ischemia may lead to findings of necrosis as well.
 Chronic congestion leads to perivenular fibrosis and ,
eventually, cirrhosis.
Normal Liver CVC Liver
Sign and symptoms
 Enlarged liver.
 Sense of fullness and tenderness in the right hypochondriac region.
 Gastrointestinal catarrh.
 Vomiting of blood.
 Jaundice
 Ascites followed by generalized edema.
 The stools are light or clay colored.
 Conditions associated with hepatic venous congestion :-
Hepatic veno- Congestive heart

occlusive failure (right
disease heart failure)
Cardiac
Cirrhosis
Budd- Chiari
sy n d ro m e Pulmonary
hypertension
Congestive
hepatopathy Constrictive
paricarditis
 Diagnosis
 With laboratory testing like liver function test(LFT)
 Radiology imaging, including ultrasound.
 Treatment
o Remove the causes.
o Medications, an intraaortic balloon pump, heart valve replacement
o An artificial heart or a heart transplant
o Liver transplant (in some cases)
SAGO SPLEEN
AMYLOIDOSIS
 Amyloidosis is the term used for a group of diseases characterized
by extracellular deposition of fibrilar proteinaceous substance
called amyloid having common morphological appearance, staining
properties and physical structure but with a variable protein
structure.
 Based on the chemical heterogenisity amyloid is composed of two
main types of complex proteins :
Fibril proteins Non- fibrillar proteins
AL AA Other proteins
AP Component apoE GAGs alpha-1 anti chymotrypsin

Protein X
1. Fibril proteins ( 95%)
Major component of amyloids is the meshwork of fibril proteins which
reveals heterogenous nature of the amyloid.
 AL protein
 AL amyloid fibril protein is derived from immunoglobulin light chain.
 It is seen in association with plasma cell dyscrasis and is included in
primary systemic amyloidosis.
 AA protein
 AA fibril protein is composed of protein with molecular weight of 8.5-kD
which is derived from larger precursor protein in the serum called SAA
( serum amyloid associated protein).
 SAA fibril protein is found in secondary amyloidosis.
2. Non fibrillar components (5%)
 Amyloid P (AP) component
 It is synthesized in the liver and is present in all types of amyloids.
 Apolipoprotein- E (apoE)
 It is a regulator of lipoprotein metabolism and is found in all types of
amyloids.
Pathogenesis
Types of Amylodoisis
Primary Amyloidosis Secondary Amyloidosis
 It is a protein misfolding and  A disorder characterized by
metabolism disorder in which the extracellular tissue
insoluble fibrils are deposited deposition of fibrils that are
in various tissues. composed of fragments of
 It is caused by idopathic SAA .
multiple myeloma, B cell  It is caused by chronic
lymphoma and other plasma infections, Ch. Non infectious
cell dyscrasias. inflammation cancer and
Familial Mediterranean fever.
SAGO SPLEEN
 Amyloidosis of spleen
Amyloid deposition in the spleen, for some unknown reason, may have
one of the following two patterns :
1. Sago spleen
2. Lardaceous spleen
1. Sago spleen
 A spleen which is affected with amyloid degeneration and in which

the amyloid is deposited in the malpighian corpuscles which
appear in cross section as a gray translucent bodies resembling
grains of sago.
 Amyloid deposits primarily involve the splenic white pulp producing
tapioca like granules on gross inspection.
 ‘Sago’ refers to – ‘SABUDANA’.
 Macroscopic Picture:
 The spleen is moderately enlarged.
 The splenomegaly is not marked.
 Consistency is rubbery and firm.
 Cut surface shows characteristic translucent pale and waxy
nodules resembling sago grains.
 Microscopic picture :
 The amyloid substance is deposited in the wall of central arterioles and

gradually replaced the white pulp only.
2. Lardaceous Spleen
 There is generally moderate to marked splenomelagaly ( weight
upto 1 kg )
 Cut surface of the spleen shows map like areas of amyloid.
 Lardaceous is Lard like ; lard means fat of pigs.
LARDACEOUS SPLEEN
SAGO SPLEEN
Amyloid is deposited in the
Amyloid deposits are limited
wall of the splenic sinusoids.
to follicles.
Not for more
time ! DRs
Your body is my
will snatch
plaques’ residence
you out
quickly!
Thank you!!!

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NUTMEG LIVER

Guided by : Dr. Paresh Sir

 Two types of congestion are there :

1. Local venous congestion – results from obstruction to the venous

2. Systemic venous congestion – is engorgement of systemic veins.

Hepatic veno- Congestive heart

Fibril proteins Non- fibrillar proteins

AP Component apoE GAGs alpha-1 anti chymotrypsin

 A spleen which is affected with amyloid degeneration and in which

 The amyloid substance is deposited in the wall of central arterioles and

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