A nutmeg liver appearance is due to a perfusion abnormality of the liver usually as result of hepatic venous congestion. When hepatic veins are congested, contrast is prevented from diffusing through the liver in a normal manner. This results in a mottled pattern of contrast enhancement in the arterial and early portal venous phase with decreased enhancement of the liver periphery. The areas of decreased enhancement are due to decreased portal flow, hepatic congestion and ischemia. On delayed images enhancement of the liver becomes more uniform.

Conditions associated with hepatic venous congestion include:

In the Budd-Chiari syndrome, the caudate lobe enhances normally as it has a separate draining vein directly into the inferior vena cava.

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