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Color Doppler energy (CDE) offers a marked improvement in sensitivity over existing color Doppler systems. We report here the use of this system in the diagnosis of small hepatocellular carcinoma (HCC). CDE was used in the clinical investigation of 13 nodules in 12 suspected cases of HCC less than 2 cm in diameter. Findings were compared with those on color Doppler imaging (CDI), angiography, angioechography and histological examination. The apparatus consisted of an Acuson 128XP 10 (ART) with 4- and 5-MHz transducers. Comparison of angiography, angioechography and CDE findings: CDE showed pulsatile flow in 8 of the 9 nodules (88.9%) in which angiography showed tumor stain or angioechography showed positive enhancement. In the 3 nodules in which staining was negative and angioechography showed negative or non-enhancement, CDE showed no pulsatile flow. Comparison between pathological and CDE findings: All 7 nodules which showed moderate or poor differentiation in pathology showed continuous pulsatile flow on CDE. Among 5 well-differentiated HCC, 4 showed no pulsatile flow and 1 showed intermittent pulsatile flow. The remaining non-malignant nodules showed no pulsatile flow. Comparison between CDI and CDE findings: Both CDI and CDE showed pulsatile flow in 8 nodules but with marked differences in sensitivity. Flow was intermittent or spotty with CDI, but mostly showed a continuous branched pattern with CDE. Thus, CDE images correlated well with angiography, angioechography and pathological findings. CDE is an effective and non-invasive means of determining the hemodynamics of small nodules and is useful in the diagnosis of small HCC.