Prognostic Value of Abdominal CT Scanning and Hepatic Histopathology in Patients with Acute Liver Failure A. OBAID SHAKIL, MBBS, BRIAN C. JONES, MD, RANDALL G. LEE, MD, MICHAEL P. FEDERLE, MD, JOHN J. FUNG, MD, and JORGE RAKELA, MD Acute liver failure has extremely high mortality without liver transplantation. We attempted to determine the value of abdominal CT scanning and liver biopsy in its management. A retrospective analysis of patients with acute liver failure was performed; demographic, clinical, radiologic and histopathologic features were noted. Over a period of 13 years, 177 patients were evaluated. The mean age was 39 years and 63% were females. The patients were divided into three groups. Fourteen percent survived with medical management (group I), 37% died (group II), and 49% had liver transplantation (group III). Most patients showed diffuse low density of the liver on CT scanning and the proportions were similar in the three groups. Moderate to large ascites was not present in group I but occurred in 31% of patients in group II and in 15% in group III. Mean hepatic volumes were similar in the three groups; however, 97% of the patients with a liver volume of less than 1000 ml either died or required liver transplantation. Liver biopsies among patients with spontaneous recovery (group I) were distinguished by the presence of regenerative changes and a hepatic parenchymal necrosis of less than 50%. These results suggest that in patients with acute liver failure a liver volume of less than 1000 ml and/or hepatic parenchymal necrosis of greater than 50% is indicative of a poor prognosis. This information may assist decision making in such patients, in particular, regarding the need for liver transplantation. KEY WORDS: fulminant hepatic failure; hepatic necrosis; hepatic encephalopathy; liver transplantation. Acute liver failure (ALF) or fulminant hepatic failure is an uncommon syndrome that is characterized by jaundice, hepatic encephalopathy, and coagulopathy in the absence of chronic liver disease (1). The dev- astating nature of the illness is evident by the case fatality rate of nearly 80%, which was reported in the pre-liver transplantation era (2, 3). Liver transplanta- tion, however, has transformed the outcome of pa- tients with ALF. It is currently the only definitive treatment, with the reported one-year survival rates ranging from 68% to 92% (4 – 6). Yet transplantation entails lifelong commitment to immunosuppression and donor organs continue to be in short supply. Accurate determination of prognosis is therefore of critical importance to assist in decision making. Among the various prognostic criteria used, the King’s College Hospital criteria have been the most extensively applied (7). However, the accuracy of the King’s College criteria has been disputed (8, 9). Our own analysis revealed that the King’s College criteria had high positive predictive value but low negative predictive value for death or transplantation (unpub- Manuscript received February 18, 1999; accepted July 21, 1999. From the Division of Gastroenterology & Hepatology, Division of Transplantation Pathology and Surgery, Department of Radiol- ogy, and Thomas E. Starzl Transplantation Institute, University of Pittsburgh, Pittsburgh, Pennsylvania. Address for reprint requests: Dr. A. Obaid Shakil, Division of Gastroenterology & Hepatology, University of Pittsburgh Medical Center, Mezzanine Level, C Wing-PUH, 200 Lothrop Street, Pitts- burgh, Pennsylvania 15213. Digestive Diseases and Sciences, Vol. 45, No. 2 (February 2000), pp. 334 –339 334 Digestive Diseases and Sciences, Vol. 45, No. 2 (February 2000) 0163-2116/00/0200-0334$18.00/0 © 2000 Plenum Publishing Corporation