Nutmeg Liver Secondary to Congestive Cardiac Failure Associated with an Elevated CA 19-9 and Hypercalcaemia: a Case Report
DOI:
https://doi.org/10.70672/wf7vnp29Keywords:
congestive hepatopathy, cholestasis, Budd-Chiari syndrome, sinusoidal obstruction syndrome, familial hypocalciuric hypercalcaemia, immobility-induced hypercalcaemiaAbstract
Nutmeg liver describes the radiological appearance of hepatic congestion, characterised by mottled heterogeneous parenchymal enhancement on a contrast-enhanced CT scan, resembling the cut surface appearance of a nutmeg. Carbohydrate antigen 19-9 (CA 19-9) is a glycoprotein tumour marker clinically associated with pancreatic and biliary malignancy. Elevation in CA 19-9 is not widely recognised to be associated with a nutmeg liver. We report a case of a 57-year-old man with systolic cardiac insufficiency causing secondary hepatic congestion (nutmeg liver) associated with an elevated CA 19-9 (252.9 U/ml) and severe hypercalcaemia (3.99 mmol/L).
We describe the diagnostic work-up and treatment strategies undertaken in this complex case. We discuss the pathophysiological mechanisms underlying different causes of congestive hepatopathy and correlate them with the subsequent elevation in CA 19-9. CA 19-9 is exclusively excreted in bile. Congestion of the hepatic sinusoidal system physically compresses intervening biliary canaliculi, leading to cholestasis and subsequently an elevated CA 19-9.
We summarise the causes of mild and marked elevations in CA 19-9, covering an array of malignant and non-malignant conditions, acting as a topic primer for further research into this field.
References
[1]. Flory M, Elsayes KM, Kielar A, Harmath C, Dillman JR, Shehata M et al. Congestive Hepatopathy: Pathophysiology, Workup, and Imaging Findings with Pathologic Correlation. Radiographics. 2024; 44 (5): e230121. doi:10.1148/rg.230121
[2]. Naik R, Adeel MY, Dahal K, Rheaume BA, Lee J. Membranous Obstruction of the IVC: Role of Advanced Imaging and Intravascular Ultrasound. JACC Case Rep. 2025; 30 (15): 103785. doi:10.1016/j.jaccas.2025.103785
[3]. Alkhouli M, Morad M, Narins CR, Raza F, Bashir R. Inferior Vena Cava Thrombosis. JACC Cardiovasc Interv. 2016; 9 (7): 629-43. doi:10.1016/j.jcin.2015.12.268
[4]. Valla DC. Hepatic vein thrombosis and PVT: A personal view on the contemporary development of ideas. Clin Liver Dis (Hoboken). 2024; 23 (1): e0246. doi:10.1097/CLD.0000000000000246
[5]. Sun C, Yang X, Wang L, Tang L, Chen J. Drug-induced sinusoidal obstruction syndrome: a real-world pharmacovigilance study based on the FDA Adverse Event Reporting System (FAERS). BMC Pharmacol Toxicol. 2025; 26 (1): 135. doi:10.1186/s40360-025-00965-5
[6]. Fan L, Stewart F, Ruiz K, Devani D, Fusco N, Gill M et al. Burden of illness of non-hematopoietic stem cell transplant-related hepatic sinusoidal obstruction syndrome: A systematic review. Heliyon. 2024; 10 (20): e36883. doi:10.1016/j.heliyon.2024.e36883
[7]. Lee T, Teng TZJ, Shelat VG. Carbohydrate antigen 19-9 - tumor marker: Past, present and future. World J Gastrointest Surg. 2020; 12(12): 468-490. doi:10.4240/wjgs.v12.i12.468
[8]. Uyanik M, Sertoglu E, Serdar MA, Aydin FN, Ozgurtas T, Kurt I. Two cases of the same family with the unusual elevation of CA 19-9 levels. Acta Med Port. 2014; 27(5): 657-60. doi:10.20344/amp.5250
[9]. Sorrentino G. Microenvironmental control of the ductular reaction: balancing repair and disease progression. Cell Death Dis. 2025 Apr 4; 16(1): 246. doi:10.1038/s41419-025-07590-4
[10]. Heer M, Baecker N, Mika C, Boese A, Gerzer R. Immobilization induces a very rapid increase in osteoclast activity. Acta Astronaut. 2005; 57 (1):31-6. doi:10.1016/j.actaastro.2004.12.007
Downloads
Published
Issue
Section
License
Copyright (c) 2026 Asian Journal of Medicine & Health Sciences
This work is licensed under a Creative Commons Attribution-NonCommercial-ShareAlike 4.0 International License.
Journal of Engineering Technology (JET) is an open-access journal that follows the Creative Commons Attribution-Non-commercial 4.0 International License (CC BY-NC 4.0)
