Liver Ultrasound

Shagufta Batool
Simple Cysts:
Simple hepatic cysts are the most common focal liver lesions. Because
the liver is such a homogeneous organ, cysts are usually easy to detect
and generally display the three classic sonographic criteria which are:
• Anechoic lumen.
• Immeasurable wall thickness.
• Well-defined back wall.
Hepatic cyst shows classic findings and obvious increased through transmission.
Complex cysts:
Cysts are referred to as complex if they have internal echoes, a thick
wall, septations that are numerous thick solid elements, or calcification.
Complex cystic lesions include :
• Hematomas.
• Abscesses.
• Biomass.
• Echinococcus.
• Cystic metastases.
• Hemorrhagic or necrotic tumors.
Cyst with multiple internal membranes
Cyst with diffuse low-level echoes (cursors) and obvious through transmission.
Polycystic liver disease:
The liver is involved in 40% to 50% of cases of autosomal dominant
polycystic disease. Despite extensive replacement by cysts, liver
function remains normal in the majority of patients unless there is
associated hepatic fibrosis.
Hemangiomas:
Hemangiomas are the most common benign liver neoplasm, occurring
in approximately 7% of adults. They are found more often in women
than men. With the exception of cysts, hemangiomas are the most
common incidental lesions detected on hepatic sonography
Sonographic features:
The typical appearance is a homogeneous, hyper echoic mass that is
usually less than 3 ·cm in size. 60 to 70 percent of hemangiomas are
typical. The margins are usually sharp and smooth, and they may be
round or slightly lobulated. Larger lesions are more likely to appear
atypical as a result of fibrosis, thrombosis, and necrosis. Calcifications
can occur but are rare.
Hemangiomas:
• Typical homogeneous hyper
echoic well-defined mass.
Focal Nodular Hyperplasia:
• It is the 2nd most common benign liver tumor after hemangioma.
• It is typically encapsulated and often has a central scar. 10 to 20 %
are multiple. FNH is supplied by an internal arterial network that is
arranged in spoke wheel pattern. They are much more common in
women (80-90%). The echogenicity of both FNH (and its scar) is
variable, and it may be difficult to detect on ultrasound. Some
lesions are well marginated and easily seen whereas other are
isoechoic with surrounding liver.
Hepatic Adenoma:
• Adenomas are rare benign tumors.
• Common in woman taking birth control pills.
• Also common in men taking anabolic steroids.

Sonographic features:
• Their sonographic appearance is varied and non specific.
• Simple small uncomplicated adenomas tend to be homogeneous and are often hypo
echoic. Internal hemorrhage or necrosis usually produces a heterogeneous appearance or
complex cystic components.
• Intratumoral fat may result in hyper echoic appearance.
• Calcifications occur in 10% cases.
Hepatocellular Carcinoma:
Hepatocellular carcinoma (HCC) is the most common primary
malignancy of the liver.' It is sometimes referred to as hepatoma.
Although HCC can occur in normal livers, it is strongly associated with
chronic liver disease, especially hepatitis Band C infection and cirrhosis.
Sonographic appearance:
The growth pattern of HCC is quite variable: it may be solitary,
multifocal, or diffuse and infiltrating. One pattern that is typical is a
large dominant lesion with scattered smaller satellite lesions.
Echogenicity is also variable, and in general the sonographic
appearance is nonspecific. Calcification and cystic changes can occur
but are very unusual. Most HCCs are hypervascular with chaotic-
appearing internal vessels. Post-contrast scans are reported to show
enhancement to a greater degree than adjacent liver parenchyma.
A and B, Color Doppler views show multiple centripetal
vessels entering the mass from the periphery (cursors) in
different patients.
Metastases:
The lungs and liver are most common sites of distant metastatic
disease. Up to 50% of patients dying of cancer have liver metastases.
Mets are multiple in up to 98% cases and usually involves both lobes of
liver. Lfts are unreliable in detecting liver metastases, therefore imaging
plays a critical role.
Sonographic appearance:
The majority of metastatic lesions have a target appearance with an
echogenic or an iso echoic center and a hypo echoic halo. When the
halo is thin it may represent dilated peritumoral sinusoids or
compressed liver parenchyma. Thick halo represents proliferating
tumor.
Metastases:
• In addition to target lesions, metastases can have a variety of
sonographic appearances. Although it is not possible to predict the
primary tumor based on the sonographic appearance of the liver
metastases, some trends are useful. Hyperechoic metastases tend to
arise from the gastrointestinal tract, most commonly from the colon.
Neuroendocrine tumors are another relatively common cause of
hyperechoic metastases. The colon is also the most common source
for calcified metastases
Liver metastases with a variety of sonographic appearances in different patients. A,
Two adjacent metastases from colon carcinoma with homogeneous hypoechoic appearance and
slightly increased through transmission. B, Multiple lesions that are confluent in areas secondary to breast cancer. All are
hypoechoic. C, Multiple metastases secondary to osteosarcoma. All are hyperechoic and similar in appearance to hepatic
hemangiomas
Pyogenic abscess:
Pyogenic liver abscesses are most often a secondary development of
seeding from intestinal sources, such as appendicitis or diverticulitis or
as a direct extension from cholecystitis or cholangitis; or from
endocarditis.
Sonographic features:
Hepatic abscesses typically appear as complex fluid collections with a
mixed echogenicity. However, it is important to realize that abscesses in
the liver may mimic solid hepatic masses. The presence of through
transmission will often provide a clue to the liquefied nature of the
mass. CT scan can differentiate between these solid masses and
abscess.
Pyogenic abscess:
It may also appear as thick-walled cystic lesions. Gas may result in
highly reflective regions with shadowing or ring-down artifacts.
Abscesses may calcify with healing. The differential diagnosis for these
various appearances primarily includes hematoma, hemorrhagic cyst,
and necrotic or hemorrhagic tumor
Large hypoechoic lesion (cursors) with increased through transmission
Fungal abscess:
Fungal infections of the liver usually occur in immunocompromised
patients; the most common organism is Candida.
Sonographic appearance:
Although it usually causes very small lesions, larger lesions occasionally
occur. The typical sonographic appearance is a target lesion with a
central echogenic region and a peripheral hypo echoic halo. Early
lesions may have a hypo echoic focus centrally, caused by necrosis and
fungal elements. This appearance has been called a "wheel within a
wheel." With healing, candidal abscesses become uniformly hyper
echoic and ultimately may calcify.
Conventional gray-scale image showing multiple tiny «1 cm) hypoechoic
lesions.
Magnified image showing multiple 1 cm or smaller lesions with a "wheel within a
wheel“ pattern.
Trauma:
In blunt abdominal trauma sonography is now being used to evaluate
hemoperitonium, however acute hepatic lacerations are difficult to
detect on ultrasound. This is because acute hematomas are often
isoechoic to liver parenchyma on ultrasound.
Trauma:
Hepatic hematomas become liquefied over a matter of days or weeks.
Because of this limitation CT is the modality of choice for detecting and
quantifying liver hematomas.
Hepatic Lacerations:
Hepatic Lacerations:
Hepatitis:
Hepatitis usually results in no detected sonographic abnormality. In
limited no of cases it can cause increased echogenicity of portal triaids,
which appear as small bright areas on views of liver peripheries. This
appearance has been referred to as starry sky sign.
Related signs:
Hepatitis can also produce marked thickening of the gallbladder wall,
contraction of the gallbladder lumen and periportal lymphadenopathy.
Fatty infiltration:
Fatty infiltration of the liver is characterized pathologically by
intracellular deposition of triglycerides within hepatocytes. Other
common causes include alcohol abuse, cholesterol-lowering
medications, and certain chemotherapy agents.
Sonograpghic appearance:
Fatty infiltration most often manifests in a diffuse distribution and
results in uniform increased echogenicity of the liver. Because the
normal liver is only slightly more echogenic than the kidney, the
diagnosis of fatty infiltration is best made by noting a marked
discrepancy between the hyper echoic liver and the less echogenic
kidney. In addition, because the normal pancreas is more echogenic
than the liver, fatty infiltration should be considered whenever the liver
appears hyper echoic compared with the pancreas.
Longitudinal view of the liver and right kidney shows marked
discrepancy between the hyper echoic liver and the normal right
Kidney.
Grade 1
Grade 2
Grade 3
Focal Spared Area:
In many cases of otherwise diffuse fatty infiltration, there will be focal
areas of spared normal liver parenchyma that appear hypo echoic with
respect to the fatty infiltrated parenchyma. If the fatty infiltration is not
recognized, the spared areas of normal parenchyma may be mistaken
as focal hypo echoic lesions. Fortunately, the spared parenchyma is
usually located in front of the right portal vein or portal bifurcation or
around the gallbladder.
Transverse view through the portal bifurcation demonstrates a
focal area of decreased echogenicity (cursors) anterior to the
portal vein secondary to focal parenchymal sparing.
Cirrhosis:
Cirrhosis is caused by hepatocellular death and resulting fibrosis and
regeneration. It occurs most commonly from alcohol abuse, which causes micro
nodular changes (1 cm). Hepatitis is the next most common cause, and it results
in macro nodular cirrhosis (nodules between 1 and 5 cm). Cirrhosis can cause
these following conditions to liver:
1. Hardening.
2. Shrinking.
3. Nodular appearance.
4. Fibrosis.
5. Hepatocellular death.
6. Impairment of liver functions.
Sonographic appearance:
Surface nodularity can easily be detected sonographically in the
presence of ascites and is a reliable sign of cirrhosis. In the absence of
ascites, surface nodularity is best detected using a high resolution
linear- or curved-array transducer focused on the liver surface.
Nodularity can also be seen where liver interfaces with structures that
are anechoic (e.g., anechoic gallbladder or hepatic veins) or echogenic
structures (e.g., perihepatic fat).
Cirrhosis:
Although the liver shrinks in advanced disease, there is frequently an
initial redistribution of liver volume toward the caudate lobe and the
lateral segment of the left lobe. Ratios comparing the size of the
caudate lobe and the right lobe have been used in the past to make the
diagnosis of cirrhosis.
Conventional views show diffuse heterogeneity and nodularity
to the liver parenchyma.
View of a hepatic vein shows multiple nodular impressions on
the hepatic vein lumen.
Portal veins
It supplies 70 % of the blood coming to the liver.
Normal diameter of portal vein is 13 mm .
Normal velocity is Approx. 18 cm/s +_ 5cm/s in fasting .
Normal peak systolic velocity is 16 – 40 cm/sec.
Proper hepatic A spectral waveform
Portal hypertension
In cirrhosis the parenchyma is damaged.
The resistance to portal venous flow increases.
Pressure above 6mmhg in the portal vein is considered portal
hypertension and above 12mmhg portal hypertension becomes
evident.