What Causes Hepatic Surface Nodularity in Fulminant Hepatic Failure?

The objective of a recent study was to assess the frequency and cause of hepatic surface
nodularity in patients with fulminant hepatic failure.

The results have shown that a nodular liver is commonly seen in patients with fulminant hepatic
failure, and this is usually secondary to a combination of confluent
regenerative nodules and necrosis.

Design
Retrospective analysis.

Participants/Methodology
This study was comprised of 35 patients who had undergone liver transplantation for fulminant
hepatic failure. There were a total of 38 ultrasound and two CT studies that
were performed prior to transplantation. CT examinations consisted of an
unenhanced scan, followed by enhanced images obtained at 20, 45, and 80 seconds
following IV contrast administration.

Ultrasound and CT images were reviewed independently by two different radiologists. Presence or
absence of hepatic surface nodularity and ascites was recorded. Following
transplantation, explanted livers were reviewed by two pathologists. Causes of
fulminant hepatic failure included hepatitis, both viral and autoimmune, drug
toxicity, Wilson’s disease, and idiopathic.

Duration of
illness for this study was defined as the number of days from onset of
fulminant hepatic failure and the date of initial imaging. The highest liver
enzyme levels between illness onset and transplantation were also recorded.

Results
There were 15 of
35 patients with fulminant hepatic failure who had hepatic surface nodularity
on ultrasound. Repeat ultrasounds, as well as CT scans performed in two of
these patients, also demonstrated surface nodularity. However, none of these
patients had cirrhosis at explant histopathology.

There was one patient
with a smooth liver surface who was found to have cirrhosis at histopathology.
There were 12 of 14 patients with surface nodularity, and one of 19 patients
with a smooth liver surface who had a combination of alternating foci of
confluent regenerative nodules and necrosis.

Presence of
ascites at time of ultrasound evaluation was not found to be significantly
different between patients with or without a nodular liver surface.

Reviewer’s
Comments
The results of
this study are useful in demonstrating that hepatic surface nodularity in
patients with fulminant hepatic failure is not a reliable sign to make a
diagnosis of cirrhosis. As noted, this has important clinical implications, as
acute-on-chronic liver disease receives a lower priority for organ
transplantation if the patient has a diagnosis of cirrhosis.

Therefore, one
should use caution in diagnosing cirrhosis solely based on presence of surface
nodularity in the setting of fulminant hepatic failure. A limitation noted in
this study was that the surface nodularity was not objectively defined or
quantified.

Author:
John C. Sabatino, MD, MSD

Reference:
Poff JA, Coakley
FV, et al. Frequency and Histopathologic Basis of Hepatic Surface
Nodularity in Patients With Fulminant Hepatic Failure.
Radiology; 2008;249
(November): 518-523.