Table 3

Comparison of guideline recommendations on focal nodular hyperplasia

	ACG (2014)27		SBH (2015)26		EASL (2016)28
Diagnostics	S	An MRI or CT scan should be obtained to confirm a diagnosis of FNH. A liver biopsy is not routinely indicated to confirm the diagnosis.	R	A diagnosis of FNH suggested by US findings should be confirmed by dynamic CT or MRI.	S	CEUS, CT, or MRI can diagnose FNH with nearly 100% specificity when typical imaging features are seen in combination.
			R		S	MRI has the highest diagnostic performance overall. The highest diagnostic accuracy by CEUS is achieved in FNH less than 3 cm.
			R	If central scars and/or other signs indicative of FNH are absent, and there is diagnostic uncertainty between HCA and FNH, the use of liver specific contrast agents is indicated.	S	If imaging is atypical refer to a BLT-MDT*.
			R		t	Perform (hepatobiliary) contrast-enhanced MRI first. Perform a CEUS when the diagnosis is uncertain and the lesion is <3 cm. Perform biopsy in case of doubt in lesions >3 cm or after CEUS.
Management	S	Asymptomatic FNH does not require intervention.	R	If a diagnosis of FNH is confirmed, conservative management is indicated. There is no specific treatment.	W	Treatment is not recommended in absence of symptoms.
Management	S	Asymptomatic FNH does not require intervention.	R	Exceptionally large nodules associated with symptoms or compression of adjacent structures should be considered for surgical resection.	S	Refer to a BLT-MDT* if the patient is symptomatic.
	W	Pregnancy and the use of CP or anabolic steroids are not contraindicated in patients with FNH.	t	Its (FNH) potential association with oestrogens is controversial and certainly less evident than that observed in HCA. (No advice given).	t	There is no indication for discontinuing CP and follow-up during pregnancy is not necessary.
Follow-up	W	Annual US for 2–3 years is prudent in women diagnosed with FNH who wish to continue CP use. Individuals with a firm diagnosis of FNH who are not using CP do not require follow-up imaging.	R	Follow-up imaging is recommended for patients with FNH who are generally asymptomatic. Control scans may be performed every 6 months to 2 years, depending on the disease course.	W	For a lesion typical of FNH, follow-up is not necessary, unless there is underlying vascular liver disease.

Green = Moderate level of evidence; Orange = Low level of evidence; Red = Very low level of evidence.
*BLT-MDT should consist of a hepatologist, hepatopancreatobiliary surgeon, diagnostic and interventional radiologist, and a pathologist.
ACG, American College of Gastroenterology; BLT-MDT, benign liver tumour dedicated multidisciplinary team; CEUS, contrast-enhanced ultrasound; CP, contraceptive pills; CT, computed tomography; EASL, European Association for the Study of the Liver; FNH, focal nodular hyperplasia; HCA, hepatocellular adenoma; MRI, magnetic resonance imaging; R, recommendation without definition of strength; S, strong recommendation; SBH, Brazilian Society of Hepatology; t, in text advice; US, ultrasound; W, weak recommendation/conditional recommendation.