Imaging description

Fulminant hepatic failure may result in fine diffuse nodularity of the hepatic surface (Figure 12.1), and should not be interpreted as indicating underlying cirrhosis.

Importance

The erroneous diagnosis of underlying cirrhosis in a patient with fulminant hepatic failure could adversely impact transplantation status, since true fulminant hepatic failure receives higher priority than acute-on-chronic liver failure.

Typical clinical scenario

In the first study to report this pitfall, 15 of 35 (43%) patients with fulminant hepatic failure demonstrated hepatic surface nodularity at pre-transplantation imaging [1]. A combination of alternating foci of confluent regenerative nodules and necrosis was seen throughout the liver in most of these patients, suggesting this is the histopathological correlate of the imaging finding (Figure 12.2).

Differential diagnosis

The nodularity associated with fulminant hepatic failure appears characteristically fine and diffuse, which is to be expected, given its histopathological basis. This particular type of nodularity has a fairly limited number of causes. The primary differential consideration is cirrhosis, and outside of the special circumstance of fulminant hepatic failure, hepatic surface nodularity is generally the most accurate and specific sign of cirrhosis [2, 3].