MODULE I

ABDOMEN II - LIVER
 LIVER SEGMENTS

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 THE LIVER
Ultrasound evaluation of liver parenchyma
Size – enlarged or reduced, normal
Configuration – Shape and position
Homogeneity and echotexture –
homogeneous, heterogeneous, hypoechoiec,
hyperechoiec, coarse
Contour – border regularity, ?nodularity
 The Liver
●
Minimally hyperechoic or isoechoic compared
to the normal renal cortex.
●
The liver is hypoechoic compared to the
spleen.
●
Spleen > liver > kidney
The Liver- ultrasound
 THE LIVER
Developmental Anomalies Hepatic neoplasms
Agenesis Benign
Position Cavernous
Vascular haemangioma
Congenital Abnormalities Focal nodular
Liver cyst hyperplasia
Adult polycystic disease Hepatic adenoma
Infectious diseases Lipoma
Viral hepatitis Malignant
Bacterial Hepatocellular
Fungal carcinoma
Parasitic Metastatic disease
Jaundice Portosystemic shunts
Metabolic disorder – fatty liver
Cirrhosis
Vascular abnomalities
Portal hypertension
Portal vein thhrombosis
Budd-Chiari syndrome
 Learning outcome:
At the end of this lesson, students should be able
to:
1. List the developmental anomalies and
congenital abnormalities.
2. Describe the sonographic appearance of liver
infectious disease.
3. Identify various pathologies of the liver.
4. Differentiate between the benign and malignant
lesion in the liver.
 THE LIVER
Developmental Anomalies

Agenesis
Incompatible with life
Agenesis of both left and right have been
reported
Compensatory hypertrophy occurs
Normal liver function test
 THE LIVER
Developmental Anomalies
Reidel's Lobe
- Long tongue like liver extending inferiorly from
right lobe.
- Usually asymptomatic, may be associated with
colonic or pyloric obstruction.
Reidel's lobe
 THE LIVER
Developmental Anomalies

Anomalies of position
Situs inversus totalis
Liver in left hypochondrium
Hernia
Omphalocoele – external abdomen
Diaphragmatic - thorax
Liver – situs Inversus
 THE LIVER
Developmental Anomalies

Vascular Anomalies
Variations of common hepatic artery
Left hepatic originating from left gastric (10%)
Right hepatic originating from SMA (11%)
Common hepatic originating from SMA (2.5%)
Portal vein
Absence of right PV – branching from main
and left
Atresias and constrictions
Hepatic veins
Variation in branching and accessories
HEPATIC ARTERY
 The Liver – congenital
abnormalities
Peribiliary Cysts
●
Small, 0.2 to 2.5 cm, asymptomatic, may
cause biliary obstruction
●
located centrally
➢
Within the porta hepatis
➢
Junction of the main right and left hepatic ducts.
 The Liver – congenital
abnormalities
Peribiliary Cysts
●
Sonography :

➢
May be seen as discrete, clustered cysts
➢
Tubular-appearing structures with thin septae,
paralleling the bile ducts and portal veins.
Peribiliary Cysts
 THE LIVER
Diffuse hepatocellular disease
Affects hepatocytes (parenchymal liver cells)
Interferes with liver function enzymes
Can be assessed through the series of liver
function tests (LFTs)
 THE LIVER
Liver function tests (LFTs)
Refers to a group of laboratory tests established to
analyze how the liver is performing under normal
and diseased conditions
The following are examples of tests :
Aspartate aminotransferase (AST)
Alanine aminotransferasee (ALT)
Lactic acid dehydrogenase (LDH)
Alkaline phosphatase (alk phos)
Bilirubin (indirect, direct and total)
Prothrombin time
Albumin and globulins
 THE LIVER
Hepatic versus obstructive disease

Hepatocellular disease – hepatocytes are

immediate problem
LFTs show increased hepatic enzyme levels
due to cell necrosis

Obstructive disease – cholestasis is when bile

excretion is blocked anywhere between the
liver and duodenum
LFTs show increased alkaline phosphatase
and direct bilirubin levels
 THE LIVER
Hepatic versus obstructive disease

Differentiation is of considerable importance

clinically
Hepatocellular – treated medically with
supportive measures and drugs
Obstructive – treated surgically

Ultrasound a useful tool in differentiating

 THE LIVER
Jaundice
Yellow discolouration of the sclerae, skin and
mucous membranes due to build up of a yellow
compound called billirubin
Elevated serum levels above 2.0 mg/dL
Increased serum alkaline phosphate and bilirubin
levels
Bile formation of the liver is one of the most
readily disrupted functions
Unconjugated hyperbilirubinaemia
Excess production of bilirubin
Conjugated hyperbilirubinaemia
Decreased hepatic excretion of bilirubin
 THE LIVER
Jaundice
Three main categories
Prehepatic jaundice
Excess production of bilirubin
Hepatic jaundice
Congenital liver disease – cirrhosis or hepatitis
Extrahepatic jaundice
Obstruction to bile drainage – cholelithisasis,
tumour
 THE LIVER
Diffuse hepatic disease
Metabolic disorders
Fatty liver
Cirrhosis
 THE LIVER
Fatty liver
Acquired, reversible disorder
Implies increased lipid accumulation in hepatocytes
Due to significant injury or systemic disorder
Excessive metabolism of fat
Causes
Obesity
Excessive alcohol intake
Poorly controlled hyperlipidaemia
Diabetes
Excess exogenous and endogenous corticosteroids
Pregnancy
Severe hepatitis
chemotherapy
 THE LIVER
Fatty liver
Sonographic findings
Varied according to the amount of fat
Deposits are diffuse or focal
Diffuse steatosis
 Fatty Liver Categories
Mild
●
Minimal diffuse increase in hepatic echotexture
●
Normal visualization of diaphragm and intrahepatic
vessels

Moderate
●
Moderate diffuse increase in hepatic echotexture
●
Slightly impaired visualization of diaphragm and
intrahepatic vessels

Severe
●
Marked increase in echogenicity
●
Poor penetration of posterior segment of the right lobe
●
Poor visualization of diaphragm and vessels
MILD FATTY INFILTRATION
MODERATE FATTY
INFILTRATION
SEREVE FATTY
INFILTRATION
 THE LIVER
Fatty liver

Focal infiltration
May mimic neoplasm
Focal sparing
 THE LIVER
Fatty liver
Features of focal change
Both types commonly involve the periportal
region (segment IV)
Preferred site of sparing
Gall bladder fossa
Liver margins
Anterior to portal vein at porta hepatus
Focal subcapsular fat – diabetics on insulin
Lack of mass effect – note non-distorted hepatic
vessels
Rapid change with time – can resolve within 6
days
FOCAL FATTY SPARING

GALL
BLADDER

FOCAL
SPARING
FOCAL INFILTRATION

Rumack et al
Focal fat infiltration
(a) geographical fat
infiltration
(b) nodular fat infiltration
(c) subcapsular
perilesional fat
infiltration
(d) hypersteatosis
(e) perivenular fat
infiltration.
Perivenular fat infiltration
Geographical fatty infiltration
Focal fat sparing
(a) geographical fat
sparing
(b) nodular fat sparing
(c) perilesional fat
sparing
(d) perivenular fat
sparing.
Anterior portal vein focal
fatty sparing
Subcapsular fatty sparing
Gall bladder fossa sparing
Perivascular fatty sparing
Focal Deposition and Focal Sparing

Slightly less common patterns are focal fat deposition
and diffuse fat deposition with focal sparing.


Characteristically occurs adjacent to the

falciform ligament

ligamentum venosum

porta hepatis

gallbladder fossa


The diagnosis of focal fat deposition and focal
sparing is more difficult than that of homogeneously
diffuse fat deposition because imaging findings may
resemble mass lesions.
Focal Deposition and Focal Sparing
THE LIVER - Infectious disease
Viral hepatitis
Hepatitis A (HAV)
Benign, self-limiting disease
Does not progress to chronic state
Does not cause a carrier state
Very rarely causes fulminant hepatitis
Fatalities very low
Spread by ingestion of contaminated water
and foods – foecal, oral route
Shed in stools and not significant in saliva,
urine, or semen
THE LIVER - Infectious disease
Viral hepatitis
Hepatitis B (HBV)
Can produce
Acute hepatitis with recovery and clearance of
virus
Nonprogressive chronic
Progressive chronic ending in cirrhosis
Fulminant hepatitis with massive liver necrosis
An asymptomatic carrier status
Blood and body fluids are primary vehicles of
transmission (parenterally)
Plays an important role in the development of
hepatocellular carcinoma
75% of all chronic carriers live in Asia
POTENTIAL OUTCOMES OF HBV

Kumar, Cotran + Robbins

THE LIVER – INFECTIOUS DISEASE
Viral hepatitis
Hepatitis C (HCV)
Major cause of liver disease
Major routes of transmission are
inoculations, blood transfusions and, IV
drug use
Rate of sexual trans mission is low
Persistent infection is a hallmark
Cirrhosis develops in 20% of persistent
infection
Fulminant hepatitis is rare
POTENTIAL OUTCOMES OF HCV

Kumar, Cotran + Robbins

THE LIVER- Infectious disease

Viral hepatitis
Other types are
Hepatits D (HDV)
Hepatitis E (HEV)
Hepatitis G (HGV)
 THE LIVER - Infectious disease
Viral hepatitis
Clinical syndromes
Carrier state
Without apparent disease
Subclinical chronic disease
Asymptomatic infection
Serologic evidence only
Acute infection
Anicteric or icteric
Chronic infection
With or without progression to cirrhosis
Fulminant hepatitis
Submassive to massive hepatic necrosis
THE LIVER- Infectious disease

Viral hepatitis

In acute hepatitis there is diffuse swelling

of the hepatocytes, proliferation of Kupffer
cells lining the sinusoids, an infiltration of
the portal areas by lymphocytes and
monocytes
THE LIVER- Infectious disease
Viral hepatitis
Sonographic appearance
Parallel histologic findings
Liver parenchyma may have diffusely
decreased echogenicity
Accentuated brightness of portal triads –
periportal cuffing
Hepatomegaly and thickened gb wall may
be associated findings
In most cases the liver appears normal
Hepatitis
Periportal cuffing
THE LIVER-Hepatic cirrhosis
WHO – cirrhosis is a diffuse process
characterised by fibrosis and conversion of
normal liver architecture into structurally
abnormal nodules
 THE LIVER
Hepatic cirrhosis
Three major pathologic mechanisms :

Cell death
Fibrosis
regeneration
 THE LIVER
Hepatic cirrhosis
Classification :
Micronodular
Nodules = 0.1 to 1.0 cm diameter
Due mainly to alcohol consumption

Macronodular
Nodules varying up to 5.0 cm diameter
Chronic viral hepatitis
 THE LIVER
Hepatic cirrhosis
Other aetiologies :

Biliary cirrhosis
Wilson’s disease - autosomal recessive
genetic disorder in which copper
accumulates in tissues
Primary sclerosing cholangitis
Haemochromatosis – iron overload disorder
 THE LIVER
Hepatic cirrhosis
Classical clinical presentation :

Hepatomegaly > 15.5 cm

Jaundice
Ascites
 THE LIVER
Hepatic cirrhosis
Sonographic appearance
Volume redistribution
Enlarged liver in the early stages
Small liver in advanced stages with relative
enlargement of the caudate lobe, left lobe,
or both, in comparison with the right lobe
Coarse echotexture
Increased echogenicity and coarse
echotexture
Liver attenuation correlates with presence
of fatty infiltration and not fibrosis
 THE LIVER
Hepatic cirrhosis
Sonographic appearance
Regenerating nodules (RN)
Represents regenerating hepatocytes surrounded by
fibrotic septa
Have similar architecture to normal liver – therefore
difficult to detect on u/s
RN tend to be isoechoic to hypoechoic on u/s
Dysplastic nodules
Larger than RN
Considered premalignant
Using doppler, Portal venous supply can be
distinguished from arterial supply to hepatocellular
carcinoma
A liver mass in patient with cirrhosis requires biopsy
HEPATIC CIRRHOSIS
HEPATIC CIRRHOSIS
 HEPATIC CIRRHOSIS

4.0 MHz CURVILINEAR 12 MHz LINEAR PROBE

PROBE
HEPATIC CIRRHOSIS
Recanalization of
paraumbilical vein
 THE LIVER
Hepatic cirrhosis
Doppler characteristics
Normal liver
Hepatic vein reflects haemodynamics of right atrium
Triphasic waveform

Cirrhosis
Diseased parenchyma alters compliance of thin
walled hv
Therefore abnormal waveforms prevail
Biphasic
Luminal narrowing of hv as disease progresses
High velocity and aliasing
Expected increase in RI of hepatic artery post
prandial does not prevail
Portal hypertension and color doppler - hepatofugal
Hepatic vein doppler
Normal Hepatic vein doppler
Clinical findings U/S findings Differential diagnosis
Fatty infiltration Echogenicity and attenuation Hepatitis
Normal to hepatic enzymes Impaired visualization of Cirrhosis
borders Metastases
Alk Phos
Hepatomegaly
Direct bilirubin
May be patchy
Acute hepatitis Nonspecific and variable Cirrhosis
AST, ALT echogenicity Fatty liver
Bilirubin Periportal cuffing
Leukopenia Hepatosplenomegaly
thickness of gall bladder wall
Chronic hepatitis Coarse hepatic parenchyma Cirrhosis
AST, ALT echogenicity Fatty liver
Bilirubin visualization of vessels
Leukopenia liver size

Cirrhosis echogenicity and attenuation Fatty liver

Alk Phos vascular markings with acute Hepatitis
Direct bilirubin Shrunken liver with chronic
AST , ALT Hepatic nodularity
Hepatosplenomegaly Portal hypertension

Haemochromatosis echogenicity through out liver Cirrhosis

Iron levels in blood Portal hypertension
 THE LIVER
Vascular abnormalities

Portal hypertension
Portal vein thrombosis
Budd-chiari syndrome
 THE LIVER-Portal hypertension
Divide into two groups
Intrahepatic/Presinusoidal
Disease affecting portal zones of the
liver
Schistosomiasis, primary biliary
cirrhosis, congenital hepatic fibrosis,
toxic substances (PVC +
methotrexate)
Cirhosis accounts for >90% of all
cases
Normal liver architecture replaced by
distorted vascular channels –
increased vascular resistence
 THE LIVER-Portal hypertension
●
Extrahepatic
Thrombosis of portal or splenic veins
●
Ascites, splenomegaly, varices
●
Normal liver Bx
 THE LIVER-Portal hypertension
Sonographic appearance
Increased portal vein diameter ≥13.0 mm with
hepatofugal.
2º signs
Splenomegaly
Ascites
Portosystemic venous collaterals

Five major portosystemic venous collaterals

Gastroesophageal varices
Paraumbilical varices
Splenorenal and gastrorenal varices
Intestinal varices
Haemroidal varices
PORTOCAVAL ANASTAMOSES

Rumack et al
Periportal collaterals/
splenic varices
 THE LIVER
Portal hypertension
Duplex doppler
Provides additional information regards direction
Has limitations, false results possible
An increase of <20% PV diameter with deep
inspiration indicates portal hypertension with
accuracy
Normal flow is undulating hepatopedal
Mean flow velocity is ~ 15-18 cm/s
Flow becomes monophasic and eventually
hepatofugal with portal hypertension
Increased splanchnic flow evident
HEPATOFUGAL FLOW
Transjugular Intrahepatic
Porto-systemic Shunt
(TIPS)
 Transjugular intrahepatic postosystemic
shunt (TIPS)
• A tract created within the liver between the
portal vein and hepatic vein using x-ray guidance
to connect two veins to reduce portal
hypertension.
• A stent is inserted to keep the shunt patent.
• Treatment for ascites, effectively decreasing
sodium retention, preventing recurrent of fluid
collection in the peritoneal cavity while waiting
for liver transplant.
Transjugular intrahepatic postosystemic shunt
 Indication for TIPS
●
Treat the complications of portal hypertension
●
Variceal bleeding, bleeding from any of the veins that
normally drain the stomach, esophagus, or intestines
into the liver.
●
Severe ascites (the accumulation of fluid in the
abdomen) and/or hydrothorax (in the chest).
●
Budd-Chiari syndrome, a blockage in one or more
veins that carry blood from the liver back to the
heart.
 THE LIVER
Portal vein thrombosis
Associated with
malignancy
Hepatocellular carcinoma, HCC
Metastatic liver disease
Pancreatic carcinoma
Chronic pancreatitis
Hepatitis
Septicaemia
Trauma
Splenectomy
Portocaval shunts
Hypercoagulability states
 THE LIVER
Portal vein thrombosis
Sonographic findings
Echogenic thrombus in lumen of pv
Acute thrombus appears anechoic
Can be missed on u/s
Portal vein collaterals
Expansion of the caliper of the vein
Cavernous transformations
Longstanding thrombosis
Malignant thrombus has high association with HCC
NORMAL PORTAL VEIN
THROMBOSED PORTAL VEIN
 PORTAL VEIN DOPLER

THROMBOSED NORMAL HEPATIC

HEPATIC PORTAL VEIN PORTAL VEIN
 THE LIVER
Budd-chiari syndrome
Rare disorder
Thrombotic occlusion of hepatic veins
Patent IVC
Degree occlusion predicts clinical course
Fatal in acute phase of liver failure
Causes
Coagulation abnormality – polycythemia rubra vera
Chronic leukaemia
Trauma
Tumour extension of HCC
Renal carcinoma
pregnancy
 THE LIVER
Budd-chiari syndrome
Sonographic appearance
Partial or complete inability to see veins
Stenosis with proximal dilation
Intraluminal echogenicity
Extensive intrahepatic collaterals
Ascites is invariable
Enlarged, bulbous liver in acute phase
Haemorrhagic infarction
Altered regional echogenicity
Infarcted area becomes fibrotic and echogenic
Spared caudate lobe
Emissary veins drain directly into IVC
INTRAHEPATIC COLLATERALS

Rumack et al
 THE LIVER
Focal hepatic disease
Hepatic cysts
May be congenital or acquired
Fluid filled space with epithelial lining
Solitary or multiple
Patients are normally asymptomatic
Incidental finding on ultrasound
Can be symptomatic
Mass effect - Compression of surrounding vessels and
ducts due to enlarged growth
Pain and Fever – secondary to infection and
haemorrhage
Frequent presence of columnar epithelium
Suggests ductal origin
Normally only appear at middle age
Occur more often in females than males
 THE LIVER
Types of cystic lesions :
Simple
Congenital or acquired
polycystic
Inflammatory
Traumatic (not true)
Parasitic (not true)
Abscess (not true)
 THE LIVER
Cystic lesions

Sonographic criteria of a simple cyst

Anechoic
Posterior acoustic enhancement
Round or ovoid shape
Smooth, thin, sharply defined far wall
 THE LIVER
Liver cyst
Ultrasound appearance
See simple cyst criteria
Complicated cysts - infection
Internal echoes
Fine, thin septations
Complex cysts
Thickened septa
Thickened wall – focal or diffuse
Solid
Nodules and Calcification
Active intervention recommended with symptomatic patients
Aspiration
Cyst ablation with alcohol
Surgical excision
CT recommended if thick septa and nodules demonstrated
HEPATIC CYST
HEPATIC CYST
HEPATIC CYST
Simple cyst complicated by
hemorrhage

Rumack et al
 THE LIVER

Adult polycystic disease

Inherited disease
Autosomal dominant
57%-74% frequency of liver cysts
LFTs usually normal
Complications such as tumor, infection and biliary
obstruction should be excluded if LFTs are abnormal
 THE LIVER

Adult polycystic disease

Ultrasound findings
Cysts are anechoic, well defined borders with acoustic
enhancement
Differential diagnosis
Necrotic metastasis
Echinococcal cyst
Haematoma
Hepatic cystadenocarcinoma
Abscess
U/S guided percutaneous aspiration for specific
diagnosis
 THE LIVER
Infectious disease

Bacterial
Fungal (candidiasis)
Parasitic (amoebiasis, hydatid, schistosomiasis)
 THE LIVER
Bacterial disease
Pyogenic bacteria enters liver via
The biliary tract – pt with supurative cholangitis
Portal vein – diverticulitis, appendicitis
Also through blunt or penetrating trauma
Clinical findings of pyogenic liver abscess
Fever
Malaise
Anorexia
Right upper quad pain
Possible jaundice in 25% patients
 THE LIVER
Bacterial disease
Sonographic appearance
U/S helpful in diagnosing pyogenic liver abscess
Varied sonographic features
Frank purulent abscess appears cystic with echo
free or highly echogenic fluid
Solid regions
Gas formation possible – dirty shadowing
Abscess wall varies from well define to irregular
thickened
PYOGENIC LIVER ABSCESS

Rumack et al
 THE LIVER
Bacterial disease
Differential diagnosis
Amoebic infection
Echinococcal infection
Simple haemorrhagic cyst
Haematoma
Necrotic cystic neoplasm
 THE LIVER
Fungal disease - Candidiasis
Secondary to haematogenous spread
Mycotic infections in other organs – mainly
lungs
Patients generally immunosuppressed
Clinical – fever in neutropenic patient
Sonographic appearances of hepatic
candidiasis
Peripheral hypoechoic zone with inner
echogenic wheel and central hypoechoic
nidus “wheel within a wheel”
“Bull’s eye”
Uniformly hypoechoic – most common
FUNGAL INFECTION

Rumack et
al
 THE LIVER
Parasitic diseases

Amoebiasis
Hydatid disease
schistosomiasis
 THE LIVER
Amoebiasis
Entamoeba histolytica most common manifestation
Transmission through foecal oral route
Parasitic protazoan follows colon, mesenteric venules,
portal vein route
Colon and stools can appear normal in pt with
amoebic liver abscess
Most common symptom is pain while diarhoea has
been reported
 THE LIVER
Amoebiasis
Sonographic appearance
Round or oval shaped lesion
Absence of prominent abscess wall
Hypoechoic
Fine-level internal echoes
Posterior acoustic enhancement
Can be similar to pyogenic liver abscess
AMOEBIC LIVER ABSCESS

Rumack et al
 THE LIVER
Hydatid disease
Echinococcus granulosus parasite
Worldwide distribution
Most prevalent in sheep - and cattle - raising
countries - Middle East, Australia
E.granulosus is a 3 to 6 mm long tapeworm
Lives in the intestine of the definitive host – usually
dogs
Intermediate host – sheep, cattle, goats
Embryos reach the liver through duodenum, portal
venous sytem
Can also pass through to lungs and kidneys
 THE LIVER
Hydatid disease
Ectocyst – 1 mm thick membrane which may calcify
Pericyst – host forms a dense connective tissue
capsule around the cyst
Endocyst – inner germinal layer

Brood capsules separate from wall – hydatid sand

Wall of hydatid cyst
Hydatid disease
Endocyst capsule
Cross section of endocyst
 THE LIVER
Hydatid disease
Sonographic appearance
Anechoic simple cyst with sand
Cysts with ruptured, detached endocyst
Cysts with daughter cysts
Densely calcified mass
HYDATID DISEASE

Rumack et al
HYDATID DISEASE

Consolidating inactive
hydatid cyst.

Rumack et al
 Hydatid disease

Large multiloculated Large complex cystic mass with

mother cyst is full of multiple small daughter cysts see
multiple small daughter as mobile sediments, likely
cysts. suggests detached daughter
cysts.
Hydatid disease
 THE LIVER
Schistosomiasis
Very common parasitic infection of humans
Hepatic involvement particularly severe
Ova reach the liver through portal vein
Chronic granulomatous reaction
Occlusion of terminal portal vein
Presinusoidal hypertension
 THE LIVER
Schistosomiasis
Sonographic findings
Widened echogenic porta tracts – up to 2 mm
Enlarged liver initially
Decreases in size as periportal fibrosis
progresses
Features of portal hypertension prevail
Splenomegaly
Varices
ascites
 THE LIVER
Hepatic neoplasms
A Focal liver mass may be incidental or identification
in a symptomatic patient
Role of u/s is to determine significant masses that
require confirmation of their diagnosis
Considerable overlap in appearances
 THE LIVER
Hepatic neoplasms

Benign
Cavernous haemangiomas
Focal Nodular Hyperplasia (FNH)
Hepatic adenoma
Lipoma
Malignant
Hepatocellular carcinoma HCC (hepatoma)
Metastatic liver disease
 THE LIVER
Cavernous haemangioma
Most common benign tumor of the liver
Most common in adult women
Discovered incidentally
Small asymptomatic lesions
Larger lesions rarely produce symptoms
Haemorrhage or thrombosis within the lesion
May enlarge during pregnancy – oestrogen
 THE LIVER
Cavernous haemangioma
Sonographic appearance
Varied
Typially small lesion - <3mm diameter
Round, oval or lobulated with well-defined borders
Homogeneous, Hyperechoic solid
Posterior acoustic enhancement – hypervascularity
Larger lesions are mixed, heterogeneous resulting
from necrosis
May be hypoechoic with background of fatty
infiltrated liver
Calcification is rare
Extremely low blood flow – not detectable using
doppler
Atypical haemangioma
CAVERNOUS HAEMANGIOMA

Rumack et al
Cavernous hemangioma
 THE LIVER
FocaL Nodular Hyperplasia FNH
Second most common benign liver lesion
Developmental hyperplastic lesion
Congenital vascular malformation
Hormonal factors may be considered
More common with women <40 years
Increased incidence associated with OC pill
Incidental finding in asymptomatic patients
Occur mainly in the right lobe of the liver
Many are subcapsular
Well circumscribed solitary mass
<5 cm in diameter
Excellent blood supply makes haemorrhage,
necrosis and calcification rare
 THE LIVER
FOCAL Nodular Hyperplasia FNH
Sonographic appearances
Often a subtle liver mass “stealth lesion”
Isoechoic solid lesion
Look for mass effect – compressed
surrounding vasculature, subtle contour
abnormalities
Central scar (spoke wheel)– central hypoechoic
linear structure
FNH

Rumack et al
Spoke wheel appearance
 THE LIVER
Hepatic adenoma
Less common than FNH
Been on the rise since 1970’s due to increased use of
OC agents
More common in women
May be asymptomatic
Palpable RUQ mass
Pain due to haemorrhage or infarction
Usually solitary, well encapsulated
Range from 8 – 15 cm
May show calcification or fat
 THE LIVER
Hepatic adenoma
Sonographic appearance
Nonspecific
May be hyperehoic, hypoechoic or isoechoic
Haemorrhage may be evident - songraphic
changes depend on duration and amount of
bleeding
Substantially less vascular than FNH
HEPATIC ADENOMA

Rumack et al
 THE LIVER
Fatty tumours – hepatic lipomas
Extremely rare
Association with renal angiomyolipomas

Sonographic appearance
Well-defined echogenic mass
Indistinguishable from haemangioma,
echogenic mets and focal fat
Liver Lipoma
 THE LIVER
Hepatocellular carcinoma HCC
One of the most common malignant tumors
High incidence in SE Asia, Japan, Greece, Italy
Male : female incidence is 5:1
Symptoms of RUQ pain, weight loss and abdominal
swelling (ascites)
Aetiology
Alcoholic cirrhosis a common predisposition
HBV and HCV of much significance
Aflotoxins
 THE LIVER
Hepatocellular carcinoma
Pathologically
Occurs in three forms
Solitary tumor
Multiple nodules
Diffuse infiltration
Propensity to venous invasion
Portal vein > hepatic vein
 THE LIVER
Hepatocellular carcinoma
Sonographic appearance
Variable
Masses are hypoechoic, complex, or echogenic
Most small (<5cm) HCCs are hypoechoic
Thin peripheral hypoechoic halo – fibrous capsule
Mass becomes more complex/inhomogenous with time
Calcification is uncommon
Small tumors may appear diffusely hyperechoic making them
indistinguishable from haemangiomas, focal fatty infiltration
and lipomas
Doppler excellent for demonstrating neovascularisation
DIFFUSE HCC
DIFFUSE HCC
HCC
 THE LIVER
Metastatic disease
At autopsy, 25% to 50% patients dying from cancer
have liver metastasis
Mets associated with HCC, pancreatic, oesophageal
carcinomas and stomach have low survival rates
MC primary sites in decreasing order :
Gall bladder
Colon
Stomach
Pancreas
Breast and lung
Most mets are haematogenous
Lymphatic spread may occur
 THE LIVER
Metastatic disease
Advantages of ultrasound
Relative accuracy
Speed
Lack of ionising radiation
Availability
Multiplanar capability – segmental localisation
 THE LIVER
Metastatic disease
Prior knowledge of primary disease is helpful with u/s
interpretation
There are no absolutely confirmatory features of
metastatic disease
Suggestive sonograhic features include
Multiple solid lesions of varied size
Hypoechoic halo
COMMON PATTERNS FOR METASTAIC
LIVER DISEASE
Echogenic mets Calcified mets
GIT Freq – mucinous
adenocarcinoma
HCC
< freq – osteogenic
Vascular primaries carcinoma
Choriocarcinoma Chondrosarcoma
Renal cell carcinoma Teratocarcinoma
Hypoechoic mets Neuroblastoma
Breast Cystic mets
Lung Necrosis – sarcomas
Lymphoma Cystic growth patterns –
cystadenocarcinoma of
Oesophagus, pancreas, ovary and pancreas
stomach Mucinous carcinoma of colon
Bull’s eye or target pattern Infiltrative patterns
lung cancer Breast cancer
Lung cancer
Malignant melanoma
METASTATIC DISEASE