Chronic Venous Congestion (Liver)

Definition

Chronic venous congestion of the liver (cardiac liver) results from right-sided heart failure causing chronic back-pressure in the hepatic veins. Grossly it produces the 'nutmeg' pattern; histologically there is dilated central veins and sinusoids, centrilobular haemorrhagic necrosis, periportal fatty change, and preserved portal triads.

General / Essential Features

• Dilated central veins and sinusoids (centrilobular)
• Centrilobular haemorrhagic necrosis (zone 3 hepatocytes)
• Eosinophilic hepatocyte cytoplasm in zone 3
• Fatty changes in periportal (zone 1) hepatocytes
• Portal triads relatively preserved
• Chronic cases: centrilobular fibrosis → cardiac cirrhosis

Sites

• Centrilobular (zone 3): primary injury site from venous back‑pressure
• Whole liver affected grossly — 'nutmeg liver' on cut surface
• Hepatic veins and IVC downstream pathology

Pathophysiology

Right heart failure → elevated right atrial pressure → retrograde transmission to hepatic veins → sinusoidal congestion → ischaemic necrosis of centrilobular hepatocytes (zone 3, farthest from portal blood supply). Atrophied hepatocytes with haemorrhagic necrosis appear red; preserved periportal hepatocytes with fatty change appear yellow — producing the nutmeg pattern.

Etiology

• Right heart failure (commonest): IHD, cor pulmonale, cardiomyopathy
• Constrictive pericarditis: Kussmaul's sign, elevated JVP
• Tricuspid regurgitation or stenosis
• Budd–Chiari syndrome: hepatic vein thrombosis — acute variant

Clinical Features

• Signs of right heart failure: raised JVP, peripheral oedema, hepatomegaly
• Pulsatile liver in tricuspid regurgitation
• Mild jaundice and elevated bilirubin
• Ascites in severe cases
• Hepatojugular reflux positive

Diagnosis

• Echocardiography: identifies underlying cardiac pathology
• LFTs: mild elevation of AST/ALT/bilirubin; low albumin in chronic disease
• CT abdomen: patchy 'mosaic' hepatic enhancement
• Liver biopsy: centrilobular congestion, necrosis, fibrosis

Treatment

• Treat underlying cardiac cause: diuretics, ACE inhibitors, beta‑blockers
• Anticoagulation: for Budd–Chiari or thrombotic causes
• Cardiac resynchronisation therapy (CRT) or cardiac transplant in refractory HF
• TIPS: for refractory ascites in cardiac cirrhosis