Liver Ultrasound

Affects the hepatocytes and interferes the liver function

Liver cell that performs liver functions, hepatic enzyme levels are elevated with cell necrosis

Interruption of bile flow through liver (from liver to duodenum)

alkaline phosphate and direct bilirubin levels increase

Elevated serum bilirubin, Decreased serum albumin, decreased clotting factor

• Increase lipid, triglicerides accumulation in hepatocytes, resulting in major liver injury or systemic disorder leading to metabolism
• It’s a benign process and may be reversible
• Usually asymptomatic patient, but some may present jaundice, nausea and vomiting, abdominal tenderness and pain

Alcoholic liver disease, diabetes mellitus, obesity, pregnancy, severe hepatitis, chronic illness, steroids

Moderate to severe shows increased echogenicity, enlarged lobe, difficulty to visualize portal vein, increased attenuation, decreased penetration, hard to see outlines of liver,

Focal regions of increased echogenicity within normal liver parenchyma. Commonly occurs at the porta hepatis

Focal regions of normal liver parenchyma within a fatty infiltrated liver. Commonly occurs adjacent to gallbladder, in the porta hepatis, in the caudate lobe and liver margins

General definition for inflammatory and infectious disease

Viral, bacterial, fungal, parasitic, medication, toxin, autoimmune disorder

Fecal / Oral

Blood / Body fluids

• Blood / Body fluids
• (indication for Liver transplant)

Elevation of ALT, AST, conjugated and unconjugated bilirubin

Most common reason for liver transplant

Greater than 90% or acute hepatitis in US

• Hypoechoic liver parenchyma, Liver enlargement,
• Hyperechoic portal vein walls, Gallbladder wall thickening
• Ranges from mild disease to massive necrosis and liver failure
• Liver cell injury, swelling and degeneration of hepatocytes leading to cell necrosis, kupffer cell enlarging, and regeneration

• Hyperechoic liver parenchyma, Small liver, Coarse liver, Decreased echogenicity of portal vein wall, Posterior soft shadowing
• Considers chronic if its least 3 to 6 month
• Nausea, anorexia, weight loss, tremors, jaundice, dark urine, fatigue, varicosities

Benign self limiting process

• Progresses to liver cirrhosis and failure
• More extensive changes

• Chronic degenerative disease of the liver
• Lobes are covered with fibrous tissue, the parenchyma degenerates, lobules are infiltrated with fat
• Simultaneous parenchymal necrosis, regeneration, and diffuse fibrosis resulting in disorganization of lobular architecture
• Chronic and progressive process, liver cell failure and portal hypertension as the end stage

Chronic alcohol abuse, hepatitis, infection

Biliary cirrhosis, fatty cirrhosis, Posthepatic cirrhosis

Asymptomatic, nausea, flatulence, ascites, light-colored stools, weakness, abdominal pain, varicosities, spider angiomas

• Symptoms – nausea, anorexia, weight loss, jaundice, dark urine, fatigue, varicosities.
• May lead to liver failure and portal hypertension

• Coarsening of liver parenchyma secondary to fibrosis and nodularity
• Increased attenuation, decreased vascular marking may present
• Hepatosplenomegaly with ascites surrounding the liver may present
• Caudate lobe and left lateral lobe may be hypertrophied with caudate to right lobe exceeding
• Nodularity of the liver edge, especially if ascites is present
• Hepatic fissure may be accentuated
• Isoechoic regeneration of nodules may be seen throughout the liver parenchyma
• Portal hypertension with or without abnormal Doppler flow may be seen

Increase incidence of hepatoma tumors within the liver parenchyma

Six types

Type I or von Gierke’s disease, abnormally large amount of glycogen is deposited in the liver and Kidneys

Hepatomegaly, increased echogenicity, slightly increased attenuation

Associated with hepatic adenomas, FNH, Hepatomegaly

Rare disease of iron metabolism, leading to cirrhosis and portal hypertension

Hepatomegaly and cirrhotic changes are the only ultrasonic findings, some increased echogenicity throughout the hepatic parenchyma

• Caused by gallstones, carcinoma of CBD, metastatic tumor invasion of the porta hepatis
• Jaundice, pruritus (itching)
• LFT – elevated direct bilirubin and alkaline phosphate
• Sonographically carcinoma of CBD shows as tubular brunching with dilated intrahepatic ducts, best seen in the periphery of the liver
• Difficult to image a discrete mass lesion
• Normal size GB, even after a fatty meal

• Distal to cystic duct may be caused by stones in the CD, an extrahepatic mass in the porta hepatis, or stricture of the CD
• CD stones cause RUQ pain, jaundice, pruritus, increase in direct bilirubin and alkaline phosphate
• Sonographically – dilated intrahepatic ducts in the periphery of the liver
• Sonographically – usually small GB, gallstones are often present, Hyperechoic lesion along the posterior floor of the GB, with sharp posterior acoustic shadow.
• Evaluation of CD may show shadowing stones within the dilated duct

• Mass in the area of the porta hepatis causes same signs as the biliary obstruction
• Sonographically – an irregular, ill-defined, hypoechoic, inhomogeneous mass lesion may be seen in the area of the porta hepatis
• Sonographically – intrahepatic ductal dilation, with hydropic GB
• Sonographically – lesion may arise from the limph nodes, pancreatitis, pseudocyst, carcinoma in head of the pancreas

• Patient is jaundiced, previous cholecystectomy
• Lab values – increase in the direct bilirubin and alkaline phosphate levels
• Sonographically – CD stricture presents as dilated intrahepatic duct with absence of a mass in the porta hepatis

• Secondary to congestive heart failure with signs of Hepatomegaly
• Lab values – normal to slightly elevated liver function test
• Sonographically – dilated IVC, SMV, HV, PV, SV
• Sonographically - venous structures may decrease in size with expiration and increase with inspiration

Displacement of the hepatic vascular radicles, external building of the liver capsule, posterior shift of IVC

Shows internal invagination or discontinuity of the liver capsule, formation of fat wedge, anteromedial shift of IVC, anterior displacement of the RK

• Solitary, non-parasitic cyst of liver
• Congenital or acquired, solitary or multiple, asymptomatic patient
• With larger cyst there is pain because of hepatic vasculature compression

• Incidental findings, asymptomatic patients
• With cyst growing there is pain or mass effect, may be infection, abscess, necrotic lesion
• More frequent in females than in males
• Sonographically – thin walls, well-defined borders, anechoic, distal posterior enhancement
• Very rarely cysts contain linear internal septa
• Calcification may be seen within the cyst wall which may cause shadowing

• Autosomal dominant and affects 1 person in 500
• 25% to 50% of patients with polycystic liver disease have one to several hepatic cysts
• 60% of patients with polycystic liver disease have associated polycystic kidney disease
• Small cysts, 2 to 3 cm, multiple cysts throughout the hepatic parenchyma
• Cysts within porta hepatis may enlarge and cause biliary obstruction
• Similar to simple cysts
• Difficult to assess an abscess formation or neoplastic lesion in a patient with polycystic liver disease
• Sonographically – anechoic, well-defined borders with acoustic enhancement
• Different diagnosis – necrotic metastasis, echinococcal cyst, hematoma, hepatic cystadenocarcinoma, abscess
• Ultrasound may be used to direct the needle if percutaneous aspiration is needed

• Hepatic abscesses – complication of biliary tract disease, surgery or trauma
• Occur in the liver: intrahepatic, subhepatic, subphrenic
• Patient presents with fever, elevated white cell counts, RUQ pain
• Search for abscess can be to locate solitary or multiple lesion within the liver, or abdominal fluid collection in Morison’s pouch in subdiaphragmatic or subphrenic space
• Infectious processes – pyogenic abscess, hepatic candidiasis, chronic granulomatous disease, amebic abscess, echinococcal disease

• Pus forming abscess, has air inside, usually in right lobe of the liver
• Gets to liver through – biliary tree, portal vein, hepatic artery, direct extension from contiguous infection, rare through hepatic trauma
• Sources of infection – cholangitis, portal pyemia secondary to appendicitis, diverticulitis, inflammatory disease, colitis, direct spread from another organ, trauma with direct contamination, infarction after embolization or from sickle cell anemia.

• Fever, RUQ pain, pleuritis, nausea, vomiting, diarrhea, elevated LFT
• Elevated liver function tests, leukocytosis, anemia
• Abscess formation is multiple in 50-67%
• Most frequent organisms are Escherchia coli and anaerobes

• Variable appearance, depending on internal consistency of the mass
• Size varies from 1 cm to very large
• Right central lobe of the liver is most common site for abscess
• Hypoechoic, round or ovoid margins, acoustic enhancement or
• complex with some derbis along the posterior margin and irregular walls
• Fluid level, if gas is present it can be Hyperechoic with dirty shadowing, complex mass, echogenic gas, reverberation artifact
• Aspiration may be needed for diagnosis

If the patient has travelled out of the US Amebic Abscess in diagnosis will be more correct than Pyogenic Abscess

• Collection of pus formed by disintegrated tissue in a cavity, caused by protozoan parasite Entaemoba histolyctia, most common extraintestinal complication of amoebic disintery
• Disease of colon, can spread to liver, lungs, brain
• Parasites reach the liver parenchyma via the portal vein
• Amebiasis is getting in with contaminated water or food
• Usually affects the colon and cecum, and remains in gastrointestinal tract
• If it invades the colonic mucosa, it may travel to the liver via portal vein
• Asymptomatic patient, may show gastrointestinal symptoms of abdominal pain, RUQ pain, diarrhea, leukocytosis, low fever, Elevated LFT

• Variable and nonspecific appearance, round or oval and lack notable defined wall echoes
• Hypoechoic lesion compared to normal liver parenchyma, Low-level echoes at higher sensitivity, internal echoes along the posterior the margin secondary to derbis
• Distal enhancement may be seen beyond the mass lesion, some organisms may rupture through the diaphragm into the hepatic capsule
• Aspiration may be needed for diagnosis

• Caused by a species of Candida
• Occurs in imunocompromised hosts: chemotherapy, organ transplant recipients, or HIV
• Candidal fungus invades the bloodstream and affects any organ, kidneys, brain, heart affects the most

Clinically Nonspecific findings, fever, localized pain

• Multiple small hypoechoic masses with echogenic central cores Bull’s eye or target lesions, “wheel-within-wheel” patterns, multiple small hypoechoic lesion
• Diagnosis can only be made with fine-needle aspiration
• Wheel within wheel – earliest stage
• Bull’s eye – calcification of hypoechoic center
• Uniformly hypoechoic focus – common presentation
• Echogenic focus – scar formation

• Small calcifications in liver and spleen
• Caused by histoplasmosis or tuberculosis infection, more common in north America, create lake basin and in mid-western US

• Recessive trait related to a congenital defect in the leukocytes that is able to ingest but not kill certain bacteria
• Occurs in children, more frequent in girls
• Pediatric patient may have recurrent respiratory infection

• Poorly marginated, hypoechoic mass with posterior enhancement
• Calcification with posterior shadowing
• Aspiration is necessary to specifically classify the mass as granulomatous disease

• Infectious cystic disease common in sheep raising countries
• Tapeworm that infects humans as intermediate most
• The eggs are getting into small intestines in humans, the larva burrow through the mucosa, enter the portal circulation, and travel to the liver
• Have two layers: inner and outer, or inflammatory reaction layer. Smaller daughter cysts may develop from inner layer, may enlarge and rupture, may also impinge on blood vessels and lead to vascular thrombosis and infarction

• Several patterns may occur, from a simple cyst to a complex mass with acoustic enhancement, may be oval or spherical with regularity of the walls, calcification may occur
• Septations, honeycomb appearance, fluid collections, “water lily” sign, that shows a detachment and collapse of the germinal layer, “cyst within a cyst”
• Sometimes the liver can have multiple parent cysts in both lobes of the liver, the cyst with the thick walls occupies a different part of the liver, tissue between the cyst is a separate parent cyst and not a daughter cyst, which is specific for echinococcal cyst

Casoni skin test, detection of antibodies: indirect hemagglutination, indirect florescent antibody test

Associated with anaphalatic shock

• One of most common parasitic infections worldwide
• Portal vein occlusion by larvae, leads to Portal hypertension, splenomegaly, varices, ascites
• Usually comes from tropical zones, but estimated that 400.000 infected persons have immigrated to US

• Occluded intrahepatic portal veins, thickening and increased echogenicity of the portal vein walls
• Distended, echogenic derbis-filled intrahepatic portal vein

Any growth of new tissue: benign or malignant

Occurs locally but is not spreading or invading to surrounding structures, may push aside or adhere to them

Uncontrolled and prone to metastasize to nearby or distant structures via the blood stream and lymph nodes

• Benign congenital tumor consisting of large, blood-filled cystic spaces, most common benign tumor of the liver, more common in females
• Asymptomatic, small percentage may bleed causing right upper quadrant pain
• Enlarges slowly and undergo degeneration, fibrosis and calcification
• Found more in right lobe: subcapsular hepatic parenchyma, or posterior right lobe than in left lobe of the liver
• Cavernous Hemangioma Sonographically –
• Hyperechoic with acoustic enhancement, round, oval, lobulated with well-defined borders, larger hemangiomas may have a mixed pattern resulting from necrosis
• May become more heterogeneous as they undergo degeneration and fibrous replacement, may also project calcification, complex anechoic echo pattern
• Differential considerations should include: metastases, hepatoma, FNH, adenoma

Tumor of the glandular epithelium, cells of tumor are arranged in a recognizable glandular structure

• Normal or slightly atypical hepatocytes, frequently containing areas of bile stasis and focal hemorrhage or necrosis
• Lesion is more common in women, and is related to oral contraceptive usage
• RUQ pain secondary to rupture with bleeding into the tumor
• Incidence is increased in patients with type I glycogen storage disease or von Gierke’s disease

• Similar to FNH, Hyperechoic with a central hypoechoic area caused by hemorrhage
• Solitary or multiple lesion, if lesion ruptures, fluid should be found in peritoneal cavity

Contains cystic structures within the lesion, rare neoplasm occurring in middle-aged women. Palpable abdominal mass

Lesion may be multilocular with mucinous fluid

• Second most common benign liver mass after hemangioma
• Found in women under 40 years of age
• Mass is thought to arise from developmental hyperplastic lesion related to an area of congenital vascular formation, asymptomatic patient
• More in right lobe of the liver
• May be more than one mass, many are located along the subcapsular area of the liver, some are pedunculated, many have central scar
• Lesion consist of: normal hepatocytes, Kupffer cells, bile duct elements, fibrous connective tissue. The multiple nodules are separated by bands of fibrous tissue
• May be increased bleeding within the tumors in these patients

Lesion appears well defined with hyperechoic to Isoechoic patterns compared with the liver, internal linear echoes may be seen within the lesions if multiple nodules occur together

• Primary malignant tumors are relatively rare in liver
• Most common tumor is hepatocellular carcinoma, developing in cirrhotic livers. Cirrhosis may be secondary to metabolic disorders or hepatitis. Tumors may also result from prolonged exposure to carcinogenic chemicals
• Ultrasound has the advantage of diagnosis
• Mild and general clinical signs of liver cancer – similar to other hepatocellular diseases.
• Symptoms include – nausea, vomiting, fatigue, weight loss, Hepatomegaly. Splenomegaly and portal hypertension are common

• Most common primary malignant neoplasm
• Pathogenesis of HCC is related to cirrhosis (80% of patients with preexisting cirrhosis develop HCC), chronic hepatitis B virus infection, and hepatocarcinogens in food
• More frequently in men, present with a previous history of cirrhosis, palpable mass, Hepatomegaly, appetite disorder and fever
• May present in one of three patients, solitary massive tumor, multiple nodules throughout the liver, or diffuse infiltrative masses in the liver
• Pathologically the tumor may present as a focal lesion, an invasive lesion with necrosis and hemorrhage, or a poorly defined lesion
• HCC can be very invasive and has been known to invade the hepatic veins to produce Budd-Chiari syndrome. The portal venous system may also be invaded with tumor thrombosis
• HCC has a tendency to destroy portal venous radicle walls, within invasion into the lumen of the vessel

• Variable appearance is noted with discrete lesions, either solitary or multiple, that are usually hypoechoic or hyperechoic, sometimes the lesions may be isoechoic and a halo may surround the lesion
• Another pattern presents as diffuse parenchymal involvement with inhomogeneity throughout the liver without distinct masses, the last pattern is a combination of discrete and diffuse echoes, hepatocellular carcinoma cannot be differentiated from metastases on ultrasound.
• Internal echoes within the portal vein, hepatic vein, IVC indicates tumor invasion or thrombosis within the vessel. Color Doppler helps to rule out presence of tumor invasion in vessels, abnormal hepatic flow is present in obstructed vessels

• Most common neoplastic involvement of the Liver. Primary sites are the colon, breast, and lung. Majority of metastases arise from a primary colonic malignancy or hepatoma
• Metastatic spread occurs when the tumor erodes the wall and travels to the liver through lymphatic system or through the bloodstream to the portal vein or hepatic artery

• Ultrasound patterns of metastatic tumor involvement in the liver vary, multiple nodes throughout both lobes of the liver.
• Three specific patterns described
• 1) Well-defined hypoechoic mass
• 2) Well-defined echogenic mass
• 3) Diffuse distortion of the normal homogeneous parenchymal pattern without a focal mass
• Hypovascular lesion produce hypoechoic patterns in the liver because of necrosis and ischemic areas from neoplastic thrombosis
• Hypervascular lesions correspond to hyperechoic patters

• Common primary masses include renal cell carcinoma, carcinoid, choriocarcinoma, transitional cell carcinoma, islet cell carcinoma, hepatocellular carcinoma
• Echogenic lesions are common with primary colonic tumors and may present with calcifications. Target type of metastases or bull’s-eye patterns are the result of edema around the tumor, or necrosis or hemorrhage within tumor. As the nodules increase rapidly in size and outgrow their blood supply, central necrosis and hemorrhage may result
• Various combinations of patterns can be seen simultaneously in a patient with metastatic liver disease. First abnormality is Hepatomegaly or alterations in contour, especially on the lateral segment of the left lobe, may be solitary or multiple, variable size and shape, sharp or ill-defined margins, metastases may be extensive or localized to produce inhomogeneous parenchymal pattern
• Ultrasound is useful to follow patients after surgery, sonographer can assess any regression or progression of tumor and change in parenchymal pattern

• Malignant neoplasms involving lymphocyte proliferation in the lymph nodes
• Two main disorders: Hodgkin’s lymphoma and non-Hodgkin’s lymphoma, can be differentiated by lymph node biopsy. No known specific causes.
• Hepatomegaly with normal or diffuse alteration of parenchymal echoes, focal hypoechoic mass is sometimes seen
• May present with enlarged, nontender lymph nodes, fever, fatigue, night sweats, weight loss, bone pain, or an abdominal mass, presence of splenomegaly or retroperitoneal nodes may help con firm the diagnosis of lymphadenopathy

• Hodgkin’s lymphoma shows up as diffuse parenchymal changes in the liver
• Non-Hodgkin’s lymphoma may appear with target hypoechoic mass lesions
• Burkitt’s lymphoma may appear intrahepatic and lucent
• Leukemia have multiple small, discrete hepatic masses that are solid with no acoustic enhancement
• Bull’s eye appearance with a dense central core may be present as a result of tumor necroses

Most common malignancies are neuroblastomas, Wilm’s tumor and leukemia

• Neuroblastoma presents as a densely reflective echo pattern with liver involvement similar to that of hepatoma
• Wilm’s tumor metastases generally invade the lung, but the liver may be secondary site
• The lesion present as a densely reflective pattern with lucencies resulting from necroses

• 3rd most organ injured in abdomen after spleen and kidney, laceration of liver occurs in 3% of trauma patients and is associated with other injured organs: the need of surgery is determined by the size of the laceration, amount of hemoperitoneum and clinical status
• Right lobe is affected more often than left lobe, the degree of trauma can vary from small to large laceration with hematoma, subcapsular hematoma or capsular disruption
• CT scan is used more often for localization of the extent of the laceration within the liver and surrounding areas, ultrasound does not clearly distinguish small lacerations in the dome of the right lobe of the liver
• Intrahepatic hematomas are hyperechoic within first 24 hours and hypoechoic and sonolucent thereafter because of resolution of the blood within the area
• Septations and internal develop 1 to 4 weeks after the trauma
• Subcapsular hematoma may appear as anechoic, hypoechoic, ceptated lenticular, or curvilinear. May be differentiated from ascitic fluid in that it occurs unilaterally, along the area of laceration. The degree of homogenicity depends on the age of the laceration.

• Is performed to eliminate irreversible disease when other treatments have failed
• Most common indications for transplantation in adults are cirrhosis, fulminant active hepatitis, congenital metabolic disorders, sclerosing cholangitis, Budd-Chiari syndrome, unresectable hepatoma
• Surgical procedure includes hepatectomy, revascularization of the new liver (hepatic artery, hepatic veins, portal venous system, IVC), hemostasis and biliary reconstruction
• Complications include rejection, thrombosis or leak, biliary stricture or leak, infection and neoplasia. Most common cause of hepatic dysfunction confirmed by clinical diagnosis and medical biopsy.
• Vascular complications: thrombosis, stricture, arterial anastomotic pseudoaneurysms. Vascular thrombosis may affect the hepatic artery, the portal vein, less common in IVC (more common in Budd-Chiari) and aorta
• The hepatic artery is the only blood supply to the bile ducts in transplant patients, identification of a stricture of a bile duct is an indication for assessment of hepatic artery patency.

Hepatic arterial occlusion, pretransplant primary primary sclerosing cholangitis, choledochojejunostomy, cholanjitis at liver biopsy, young aged

• Important role in pre and post operative evaluation
• Primary role is to evaluate the portal venous system, hepatic artery, IVC, and liver parenchymal pattern. Vasculature is assessed for size and patency in preoperative evaluation. Also needs to evaluate the biliary system for dilation and portosystemic collateral vessels

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