A 40-year-old woman with polycythaemia vera develops sudden abdominal pain, ascites, and tender hepatomegaly over one week. Doppler ultrasound shows absence of flow in the hepatic veins. Liver biopsy would be expected to show:

• A Portal tract fibrosis with ductular proliferation and cholangitis
• B Centrilobular congestion with necrosis and sinusoidal dilatation, sparing portal tracts early ✓
• C Massive panlobular coagulative necrosis of all acini
• D Perisinusoidal zone 3 fibrosis with ballooned hepatocytes

Explanation

This is Budd-Chiari syndrome from hepatic vein thrombosis, classically associated with myeloproliferative neoplasms via JAK2 mutation. Obstruction to venous outflow produces a nutmeg liver with severe centrilobular congestion, sinusoidal dilatation, and zone 3 necrosis while portal tracts remain relatively spared early on. Option A describes biliary obstruction, C describes fulminant viral or toxic hepatitis, and D describes steatohepatitis, none of which match the clinical picture.

Reference: Robbins and Cotran Pathologic Basis of Disease, 10th ed.

High-yield for: NEET PGINI-CETNExTFMGEUSMLEPLABMRCP

Written and medically reviewed by the StethoPrep medical team.