Introduction nutmeg Due to dual blood supply the liver does not typically infarct Flow can be obstructed in 3 places pre-hepatic caused mainly by vessel thrombosis login to view 4 more bullets intra-hepatic causes login to view 4 more bullets post-hepatic caused by thrombosis of hepatic vein due to login to view 3 more bullets Budd-Chiari syndrome login to view 25 more bullets Presentation Physical exam pre-hepatic portal hypertension ascites NO hepatomegaly intra-hepatic hepatomegaly portal hypertension ascites post-hepatic hepatomegaly portal hypertension ascites Evaluation Intra-hepatic liver biopsy "nutmeg" appearance login to view 1 more bullet labs ↑ transaminases Post-hepatic ultrasound is test of choice labs ↑ transaminases