Striking case of Budd-Chiari syndrome with a late presentation due to several months of symptoms, resulting in relatively small caliber (but occluded) hepatic veins and intrahepatic segment of the IVC. Accounting for the nutmeg perfusion is key in making this diagnosis, as your major other consideration would be right heart disease. The right heart size is normal, and thus careful interrogation of the vasculature can lead you to this diagnosis.