Nutmeg liver: Centri-lobular region is depressed (cell death) with adjacent parenchymal accentuation giving this appearance. HPE: Centri-lobular hemorrhage, with variable degree of hepatocyte necrosis and drop outs. Most common cause is right hea failure (increases IVC pressure, that increases central venous pressure and congestion in liver) and left hea failure ( hypoperfusion and ischemia) Right-sided hea failure leads to passive congestion of the liver. On gross examination: liver is mildly enlarged and cyanotic. It often has rounded edges. Microscopically there is congestion of centrilobular sinusoids. Later, hepatocytes become atrophic, resulting in markedly attenuated liver cell plates. Left-sided hea failure or shock: causes liver hypoperfusion and hypoxia, leading to ischemic coagulative necrosis of hepatocytes in the central region of the lobule which is the centrilobular necrosis. Clinically evident as transient elevation of serum aminotransferases or jaundice