Nutmeg Liver Secondary to Congestive Cardiac Failure Associated with an Elevated CA 19-9 and Hypercalcaemia: a Case Report

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.