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9.2 Diffuse Changes
Schmidt, Ultrasound © 2007 Thieme
All rights reserved. Usage subject to terms and conditions of license.
a b
Fig. 331a, b Decompensated alcoholic cirrhosis. a Discontinuities in the capsule
(arrows). A = ascites. b Apparent breaks in the capsule due to the lobulated
liver surface. “Brush” or “file” appearance due to fine surface nodularity
(after Rettenmaier)
Table 43.Sonographic signs indicating the etiology of cirrhosis
yyyyyyyyyyyyyyyyyyyyyyyyyyyyyyyyyyyyyyyyyyyyyyyyyyyyyyyyyyyyyyyyyyyyyyyyyyyyyyyyyyyyyyyyyyyyyyyyyyyyyyyyyyyyyy
Hepatic cirrhosis Alcoholic cirrhosis Congestive cirrhosis
yyyyyyyyyyyyyyyyyyyyyyyyyyyyyyyyyyyyyy
Coarsening of the parenchymal
echo pattern
Bulging contours Fine, diffuse coarsening
Hypoechoic regenerative
nodules (caution: primary
hepatic carcinoma!)
Altered vascular architecture on
CDS (curved veins with irregular
calibers, “pruned” portal veins,
dilated hepatic artery)
yyyyyyyyyyyyyyyyyyyyyyyyyyyyyyyy y
Organ enlargement
yyyyyyyyyyyyyyyyyyyyyyyyyyyyyyyyyyyyyy
Enlarged liver
Mostly smooth but often
of the echo pattern
bulging contours, good
through transmission due to
hepatic venous congestion
(no luminal change with
respirations)
Increased echogenicity Vena cava congestion
Distal acoustic shadowing No bowing of vessels or
caliber irregularities by CDS
Small contour bulges with
Ascites
breaks in the capsule
(brush or file appearance)
Altered vascular architecture on CDS
9
Liver9Liver9Liver
n
Diffuse metastasis or hepatic metastases during chemotherapy, systemic
hematologic diseases
x
Increased parenchymal echogenicity
x
Distal acoustic shadowing (as in a fatty liver)
x
Slightly irregular or hazy echo pattern
x
Bulging contours
x
CDS: vascular displacement, infiltration, spot-like vascul arity
x
Possible associated finding: microcalcification
(Figs. 332 and 333):
239
9.2 Diffuse Changes
Schmidt, Ultrasound © 2007 Thieme
All rights reserved. Usage subject to terms and conditions of license.
9
Liver9Liver9Liver
ab
Fig. 332a, b Metastatic liver in a patient with colorectal carcinoma. a B-mode:
heterogeneous parenchymal echo pattern with no evidence of discrete metastases.
b CDS: A normal vascular architecture is no longer detectable. The irregular spots
of vascularity indicate the extent of liver destruction
Fig. 333 Chronic myeloid leukemia
with diffuse cellular infiltration: slight
coarsening of the parenchymal echo
pattern with distal acoustic shadowing
Interpretation and Further Testing
..............................................................................................................
n
Role of sonography: Ultrasound cannot replace histology, but it can do the fol-
lowing:
x
Detect previously unknown findings with high confidence
x
Narrow the differential diagnosis based on sonographic features
x
Classify a clinically presumed liver disease as diffuse or focal, often permitting a
specific diagnosis to be made
x
Eliminate or lessen the need for invasive endoscopic procedures (laparoscopy)
x
Provide an accuracy rate of almost 80 % in the diagnosis of hepatic cirrhosis
n
Indications for histology:
x
Diagnosis of hepatitis and evaluation of its inflammatory activity
x
Differentiation of hepatitic cirrhosis from siderocirrhosis; differentiation of
alcoholic fatty liver from diabetic or toxic drug-induced fatty liver and from a
storage disease
n
Further tests : These depend upon sonographic and clinical findings:
x
Findings characteristic of a fatty liver:
– Additional tests are unnecessary unless there is a discrepancy between clin-
ical and ultrasound findings. In this case an ultrasound-guided percutaneous
liver biopsy should be done to differentiate other conditions with a similar
240
9.3 Circumscribed Changes
Schmidt, Ultrasound © 2007 Thieme
All rights reserved. Usage subject to terms and conditions of license.
echo pattern: chronic hepatitis C, Gaucher disease, toxic liver disease, NASH,
diffuse malignant infiltrates
– Only exceptional cases require confirmation by blind liver biopsy (after
locating the puncture site sonographically) or by laparoscopy
x
Suspected metastasis or unexplained ascites:
– Laparoscopy and histologic evaluation
– Sonography: use CDS, contrast-enhanced sonography, and THI
– Other imaging studies such as CT angiography and MRI
x
Symptoms of cholestasis (e.g., sclerosing cholangitis): Evaluate by ERC.
9.3 Circumscribed Changes
Overview (Table 44):
..............................................................................................................
Table 44.Circumscribed hepatic changes
yyyyyyyyyyyyyyyyyyyyyyyyyyyyyyyyyyyyyyyyyyyyyyyyyyyyyyyyyyyyyyyyyyyyyyyyyyyyyyyyyyyyyyyyyyyyyyyyyyyyyyyyyyyyyy
Anechoic Hypoechoic Isoechoic Echogenic, hyperechoic
yyyyyyyyyyyyyyyyyyyyyy
Hepatic cysts
(p. 242)
Portal vein ectasia
(p. 243)
Aneurysms,
shunts (p. 243)
Cystic lesions
(p. 244)
yyyyyyyyyyyyyyyyyyyyyyyyyyyyyyyy y
Focal sparing in fatty
infiltration (p. 245)
yyyyyyyyyyyyyyyyyy
Atypical
lobulation
yyyyyyyyyyyyyyyyyyyyyyyyyyyyyyyyyyy
Diaphragmatic crura
(p. 251)
(p. 251)
Hypoechoic transformation of the caudate lobe
(p. 246)
Regenerative nodule in
hepatic cirrhosis (p. 246)
Isoechoic
metastases
(p. 251)
Focal nodular
hyperplasia
Focal fatty infiltration
(p. 252)
Echogenic ligamentum
teres (p. 252)
(p. 248)
Hemorrhagic hepatic cyst
(p. 247)
Portal vein thrombosis
Echogenic portal tracts
(“starry sky”) (p. 253)
Fresh hematoma (p. 253)
(p. 247)
Abscess (p. 247) Hemangioma (p. 253)
Focal nodular hyperplasia
Lesions in porphyria (p. 254)
(p. 248)
Adenoma (p. 248) Primary hepatic carcinoma
(p. 254)
Atypical hemangioma
(p. 49)
Metastasis (colon
carcinoma, carcinoid,
p. 254)
Primary hepatic
Calcification (p. 254)
carcinoma (p. 49)
Metastases (p. 250) Intraductal stones (p. 254)
Systemic hematologic
Pneumobilia (p. 254)
diseases (p. 250)
Hemorrhagic cyst (p. 254)
9
Liver9Liver9Liver
241
9.3 Circumscribed Changes
Schmidt, Ultrasound © 2007 Thieme
All rights reserved. Usage subject to terms and conditions of license.
9
Anechoic Changes
..............................................................................................................
Liver9Liver9Liver
n
Liver cysts (Figs. 334–336): congenital or acquired. May be solitary or multiple
and may occur in a cystic liver, as biliary cysts, or in Caroli syndrome
x
Solitary and multiple cysts:
– Anechoic round lesions (or elliptical when flattened by other organ struc-
tures; show tapered extensions when close to portal tracts); smooth margins
– Distal acoustic enhancement
– Weakly echogenic wall (with edge shadowing)
– Occasional septations
– High-resolution scan may provide an edge-on view of the cyst wall
– Associated mass effects (on vessels, vena cava, or portal vein)
x
Cystic liver: greatly enlarged liver of variable size (i 17–20 cm). In 50 % of
patients other organ systems are involved (polycystic kidneys, pancreatic cysts)
x
Biliary cysts : Ultrasound can define the affected bile duct, which occasionally
contains a stone.
x
Caroli syndrome (congenital dilatation of the intrahepatic bile ducts, Fig. 336):
segmental, saccular dilatation of the bile ducts
ab
cd
Fig. 334a–d Cystic masses in the liver. a–c Simple cysts (C). a Typical cystic criteria
with wall echoes (arrows). b Septated cysts. c CDS: no internal vascularity.
d Multiple anechoic round masses with acoustic enhancement posterior to the cysts
242
9.3 Circumscribed Changes
Schmidt, Ultrasound © 2007 Thieme
All rights reserved. Usage subject to terms and conditions of license.
9
a b
Liver
Gallbladder
Cys t
Fig. 335a–c Cystic lesions: a, b Stone
Stone
c
in a biliary cyst communicating with the
right hepatic duct (confirmed at
operation): incomplete acoustic shadow. The patient presented clinically
with biliary colic (but no stones in the
gallbladder). c Peliosis hepatis. The
appearance is similar to that of hepatic
cysts (left), but the liver presents an
irregular, patchy hypoechoic structure
with multiple echo-free cystic masses
up to 10 mm in size (arrows). When the image is magnified, the relationship of the
cysts to portal vessels can be appreciated. IVC = inferior vena cava
ab
Liver9Liver9Liver
Fig. 336a, b Cystic dilatation of intrahepatic bile ducts (C) in Caroli syndrome.
a Stones and incomplete shadowing (arrow) with intra- and extrahepatic duct
stones. b Residual intrahepatic stones (arrow) following operative treatment;
cystic duct expansion has resolved
n
Portal vein ectasia (peliosis hepatis; rare; Fig. 335):
x
Multiple round or oval, tapered, or angular anechoic lesions that communicate
with portal venous branches
x
No detectable Doppler flow
n
Hepatic artery aneurysm, arteriovenous shunts, Osler disease:
x
Round, anechoic, pulsating lesion
x
Communicates with the artery (Doppler signal, color flow detection by CDS)
243
9.3 Circumscribed Changes
Schmidt, Ultrasound © 2007 Thieme
All rights reserved. Usage subject to terms and conditions of license.
9
n
Cystic lesions (Figs. 337–339): inflammatory, infectious (echinococciasis,
abscess), traumatic (hematoma), or neoplastic (cyst-like metastasis, regressive
Liver9Liver9Liver
liquefied metastasis)
x
Echinococcal cyst (E. granulosis, Fig. 337): anechoic round lesion (see also cystic
liver, p. 153) echogenic wall, and calcifications in cystic echinococcosis
n
Note: Alveolar echinococciasis (E. multilocularis = fox tapeworm) presents as a
solid, infiltrating tumor-like mass.
x
Hematoma, abscess (Fig. 338): usually has irregular margins without a cyst
wall. May contain low-level internal echoes
x
Cyst-like metastases (Fig. 339)
ab
c
d
e
Fig. 337a–e Cystic echinococcosis.
a Type I WHO*. b Heavily encapsulated
polycystic lesion with numerous septa
and minor calcification, type IIB according to Koischwitz. c Type III WHO.
d Type IV WHO. e Type V WHO (*WHO
classification of cystic echinococcosis
cysts; images c and e courtesy of
Dr. Benazzouz, Rabat, Marocco and
image a of Dr. Kratzer, Ulm, Germany)
244
9.3 Circumscribed Changes
Schmidt, Ultrasound © 2007 Thieme
All rights reserved. Usage subject to terms and conditions of license.
Fig. 338 Hematoma (H) in the
upper portion of the left liver (L).
Detected incidentally several weeks
after resuscitation
Hypoechoic Changes
..............................................................................................................
n
Focal sparing of the liver in fatty infiltration (Figs. 340 and 342):
x
Most commonly found in the periportal region and adjacent to the gallbladder
bed of the liver
x
Elliptical to triangular shape
x
May occasionally show a patchy or flame-shaped distribution throughout the liver
a
b
Fig. 339a, b Carcinoid metastases (neuroendocrine tumor). a Typical,
predominantly liquefied mass lined by peripheral, echogenic tumor tissue.
b CDS demonstrates a hypervascular mass (unlike other metastases)
9
Liver9Liver9Liver
Fig. 340 Focal sparing in fatty infiltration; Polygon-shaped hypoechoic area
(arrow) adjacent to the gallbladder bed
of the liver
Fig. 341 Hypoechoic quadrate lobe
(segment IV, arrows) adjacent to the
gallbladder (GB) in an otherwise fatty
liver
245
9.3 Circumscribed Changes
Schmidt, Ultrasound © 2007 Thieme
All rights reserved. Usage subject to terms and conditions of license.
9
Liver9Liver9Liver
ab
Fig. 342a, b Regional differences in fatty infiltration with focal sparing (arrows) in
segment VIII between the right and left hepatic veins (HV), which pass unchanged
through the spared area. No additional tests were required.
a B-mode image, b CDS
n
Decreased echogenicity of the caudate lobe (Fig. 343 ):
x
Relatively coarse, hypoechoic texture
x
Enlarged liver with bulging contours in hepatic cirrhosis
Fig. 343 Decreased echogenicity of the
caudate lobe (CL, segment I) anterior
to the vena cava (VC) in an otherwise
normal-looking liver
n
Regenerative nodule in a cirrhotic liver (Fig. 344):
n
Note: Differentiation is mainly required from primary hepatocellular carci-
noma
x
Pea- to cherry-sized nodule
x
Intrahepatic regenerative nodule: round, hypoechoic
x
Peripheral regenerative nodule: rounded bulge in the liver contour
Fig. 344 Regenerative nodule in
severe alcoholic toxic cirrhosis (arrow),
246
confirmed cytologically
9.3 Circumscribed Changes
Schmidt, Ultrasound © 2007 Thieme
All rights reserved. Usage subject to terms and conditions of license.
n
Hemorrhagic liver cyst (Fig. 345):
x
Hypoechoic mass with smooth margins
x
Internal echoes are often seen with position changes
Fig. 345 Hemorrhagic liver cyst :
hypoechoic, sharply circumscribed mass
with a faintly echogenic wall
n
Intrahepatic portal vein thrombosis (Fig. 346):
x
Round, elliptical or elongated, depending on the plane of section
x
Loose echo texture, isoechoic to slightly hypoechoic
Fig. 346 Intrahepatic portal vein
thrombosis (VT): enlarged vessel lumen
with intraluminal echoes. All of the small
branches (hypoechoic foci) are thrombosed together with the main trunk and
tributaries. Clinical presentation: portal
vein thrombosis with a fatal outcome.
C = liver cyst
n
Abscess (Fig. 347):
x
Hypoechoic (anechoic) to hyperechoic, heterogeneous echo pattern
x
Irregular margins, frequently ill-defined
x
Often contains fine, echogenic gas bubbles with incomplete acoustic shadows
or reverberations
x
Hyperechoic pyogenic membrane is often present
9
Liver9Liver9Liver
a
b
Fig. 347a, b Liver abscess. a Liver abscesses resulting from septic cholangitis:
lesions with ill-defined margins (arrows). b Liver abscess resulting from the biliary
spread of infection: nonhomogeneous mass with ill-defined margins, a faintly
hypoechoic rim, and central liquefaction (CL). The lesion is avascular on CDS
247
9.3 Circumscribed Changes
Schmidt, Ultrasound © 2007 Thieme
All rights reserved. Usage subject to terms and conditions of license.
9
n
Focal nodular hyperplasia (FNH, Fig. 348):
x
Hypoechoic round or elliptical mass, usually with smooth margins
Liver9Liver9Liver
x
Echo pattern is often heterogeneous due to the presence of (central) connective
tissue (= scars)
x
Echogenic extensions radiating toward the periphery (stellate scar)
x
CDS: vessels passing through the radial connective tissue (“spoked-wheel”
pattern)
ab
Fig. 348a–c Focal nodular hyperplasia.
a Hypoechoic mass (arrows) in segment
III. PV = central portal vein, CL = caudate
lobe. b Magnified view: faint central
stellate scar (echogenic star-shaped
structure). c CDS: “spoked-wheel”
pattern of vascularity. The stellate scar
and spoked-wheel pattern establish the
c
n
Adenoma (Fig. 349; see p. 450) : resembles in B-mode FNH, as it consists entirely
diagnosis; an additional contrast
enhanced us (see p. 450) is helpful
of hepatocytes and blood vessels:
x
Uniformly isoechoic or hypoechoic mass
x
Smooth margins
ab
Fig. 349a, b Liver adenoma. a Isoechoic tumor with focal anechoic necrosis/
hemorrhage. b Power Doppler: distinctive vascularization with arterial supply.
Histology: hepatocellular adenoma
248