- Appearance: Well-defined, black with posterior enhancement
- Examples: Simple cyst, biliary cyst
- Significance: Typically benign
- Appearance: Darker than liver, poorly marginated or irregular
- Examples: Liver abscess, metastases, early HCC, lymphoma
- Significance: Needs Doppler/CEUS/biopsy for confirmation
- Appearance: Same echogenicity as liver → “invisible” on grayscale
- Examples: HCC, hemangioma (sometimes)
- Tips: Look for capsular bulge, distortion, or use Doppler/CEUS
- Appearance: Brighter than normal liver tissue
- Examples: Hemangioma (most common), focal fatty change, calcified metastases
- Clues: Hemangioma often shows posterior enhancement and peripheral nodular enhancement on CEUS
- Appearance: Irregular internal echoes, septations, solid + cystic parts
- Examples: Necrotic metastases, hepatoblastoma, complex abscess
- Red Flag: Always needs further investigation
- Well-defined, smooth borders typically indicate benign lesions, such as simple cysts or hemangiomas.
- Shape & Echogenicity: Hemangiomas often appear as small (<3 cm) uniformly hyperechoic lesions These bright lesions “stand out” clearly against the liver parenchyma.
- Borders: They exhibit smooth, sharp margins, distinguishing them sharply from surrounding tissue—a hallmark of benign lesions
- Posterior Enhancement: Frequently seen as increased brightness deep to the lesion, known as posterior acoustic enhancement
- Doppler Flow: Often lacks visible blood flow on color or power Doppler due to its slow-flow vascular nature
- if the lesion is larger than 3 cm, shows atypical features, or the patient has high-risk factors, contrast-enhanced ultrasound (CEUS) or further imaging like CT/MRI may be recommended for confirmation
- Ill-defined or irregular borders often suggest malignant or infiltrative lesions, including hepatocellular carcinoma (HCC) or cholangiocarcinoma.
- Classic simple liver cyst: Appears as a sharply demarcated, anechoic (completely black) round lesion with a smooth, thin wall on ultrasound
- The images above clearly show smooth margins and a thin cyst wall, indicating a benign nature without septations, mural nodularity, or complex features
- Anechoic interior: Lesion appears completely dark, typical of fluid content .
- Smooth, thin walls: Clearly defined, separating the cyst from liver tissue
- Posterior acoustic enhancement: Increased brightness behind the cyst due to sound waves passing through fluid
- No internal septations or solid components: Helps differentiate simple cysts from complex or parasitic lesions
- A thin peripheral halo or rim is considered a classic feature of HCC or metastatic lesions, warranting further evaluation.
- Thickened, nodular, or multiloculated borders may point toward necrotic tumors, abscesses, or parasitic cysts like hydatid disease.
- Capsular bulging suggests mass effect and is often seen in large or exophytic lesions.
- the renal cortex (of the right kidney)
- and usually also slightly brighter or equal to the spleen.
Size: Normal / Enlarged / Reduced (e.g., liver length at midclavicular line: XX cm).
1. Echogenicity Assessment of liver lesions
| Type of Echogenicity | Description | Common Lesion Examples | Interpretation |
|---|---|---|---|
| Anechoic | Completely black, no internal echoes | Simple cyst, bile duct, vascular structures | Fluid-filled, benign |
| Hypoechoic | Darker than liver parenchyma | Abscess, metastasis, HCC (early), lymphoma | Suspicious, may be solid or inflammatory |
| Isoechoic | Similar echogenicity to surrounding liver | HCC, hemangioma | Can blend into background—needs Doppler or contrast |
| Hyperechoic | Brighter than liver parenchyma | Hemangioma, focal fat, calcification, metastasis | Often benign, but not always |
| Mixed echogenicity (heterogeneous) | Both hypoechoic and hyperechoic areas | Necrotic tumors, complex cysts, metastasis | Suggests complex lesion—needs further workup |
| Lesion Type | Echogenicity | Common Diagnosis | Diagnostic Step |
|---|---|---|---|
| Simple cyst | Anechoic | Benign cyst | No further workup if classic |
| Solid round mass | Hypoechoic | HCC, metastasis | Doppler, CEUS, Biopsy |
| Bright lesion | Hyperechoic | Hemangioma, fat focus | CEUS or MRI for certainty |
| Mixed pattern | Heterogeneous | Necrotic tumor, abscess | Biopsy or advanced imaging |
| Invisible lesion | Isoechoic | Isoechoic HCC | CEUS or MRI |
2. Border Assessment of liver lesions
| Feature | Capsular Bulging Lesion | Non-Bulging Simple Cyst |
|---|---|---|
| Capsule contour | Protrudes outward, causing a visible bulge | Remains smooth, no bulging |
| Lesion location | Subcapsular / exophytic | Intrahepatic |
| Appearance | Solid or complex mass, may stretch capsule | Anechoic, fluid-filled, smooth-walled |
| Clinical concern | Higher likelihood of large tumor or malignancy | Benign; asymptomatic, incidental finding |
| Border Type | Ultrasound Description | Possible Diagnosis | Next Step |
|---|---|---|---|
| Well-defined, smooth | Sharp margins, clear separation from liver parenchyma | Simple cyst, hemangioma, metastasis | Often benign; confirm with CEUS/MRI if needed |
| Irregular or ill-defined | Blurry or spiculated edges blending into liver tissue | HCC, cholangiocarcinoma, infiltrative lesions | Require Doppler, CEUS, biopsy |
| Thin peripheral halo | Hypoechoic rim around lesion ("halo sign") | Often HCC or metastasis | Suggests malignancy; further imaging |
| Thick or nodular rim | Heterogeneous or complex border with nodularity | Necrotic tumor, abscess | CEUS/CT for clarification |
| Multiloculated border | Multiple septations or compartments within lesion | Cystic metastases, hydatid cyst | Correlate with serology/CT |
| Capsule bulging | Lesion causing bulge in liver contour | Large hemangioma or exophytic mass | Evaluate mass effect with CT/MRI |
Biliary Tree: Intrahepatic ducts – dilated / not dilated.
Additional Findings .
Ascites: Not present / Present (quantify or localize if possible).
Lymphadenopathy: None detected / Present (describe location and size).
Adjacent Organs: (e.g., pancreas, right kidney) – mention any incidental findings.
Normal liver ultrasound: No evidence of sonological abnormalities.
Abnormal Findings: For example-
Features suggestive of hepatic steatosis
Recommendations
1. size
Normal: Right lobe within normal range at midclavicular line.
Enlarged: (Hepatomegaly) right lobe >15.5 cm at midclavicular line.
Reduced: seen in chronic liver disease.
2. Liver Echotexture
Homogeneous: normal, uniform parenchymal appearance.
Heterogeneous: irregular or mixed echogenicity, may suggest fibrosis, inflammation, or cirrhosis.
Coarse: indicative of chronic liver disease (e.g., cirrhosis).
Fine: normal parenchymal texture.
3. Liver Echogenicity
Normal echogenicity The hepatic parenchyma appears slightly more echogenic (brighter) than:
Markedly increased indicates severe steatosis, obscures portal veins.
Decreased echogenicity may indicate acute hepatitis or infiltrative disease.
4. Liver Contour
Smooth:normal.
Irregular: may suggest fibrosis or early cirrhosis.
Nodular: typically seen in established cirrhosis
Bulky lobes: enlarged caudate or left lobe in cirrhosis.
5. Focal Liver Lesions
By Echogenicity:
Hyperechoic: Bright compared to liver (e.g., hemangioma, lipoma).
Hypoechoic: Darker than liver (e.g., metastasis, abscess).
Isoechoic: Similar to surrounding liver (may be subtle).
Anechoic: Completely black (e.g., simple cyst).
By Appearance:
Well-defined / Poorly defined.
Homogeneous / Heterogeneous
Solid / Cystic / Complex
Target / Halo sign suggests metastasis
Calcified lesion echogenic with posterior shadowing
Vascularity (with Doppler):
Hypervascular / Hypovascular / Avascular
Internal flow / Peripheral flow
6. Biliary Tree
Normal caliber ducts no dilation
Intrahepatic ductal dilatation parallel channel sign
CBD:
Normal (<6 mm pre-cholecystectomy, <10 mm post-cholecystectomy)
Dilated
Presence of intraductal stone / mass / sludge
Patency: Patent / Thrombosed / Absent
Flow direction: Hepatopetal (normal) / Hepatofugal (abnormal)
Flow pattern: Monophasic / Triphasic
Flow pattern: Monophasic / Triphasic
7. Portal Vein and Hepatic Vasculature
Patency: Patent / Thrombosed / Absent
Flow direction: Hepatopetal (normal) / Hepatofugal (abnormal)
Flow pattern: Monophasic / Triphasic
Velocity: Normal / Increased / Decreased
8. Associated Findings
Ascites: Anechoic fluid in perihepatic, perisplenic, or pelvic regions
Splenomegaly: May accompany portal hypertension
Lymphadenopathy: Enlarged nodes near porta hepatis
Pericholecystic fluid / Gallbladder wall thickening
9. Doppler Terms
Monophasic flow: Often abnormal in hepatic veins
Triphasic flow: Normal hepatic vein waveform
Continuous flow: Seen in portal hypertension
Tardus-parvus waveform: Suggests arterial stenosis
Tardus = Latin for “slow” – indicates a delayed systolic upstroke
Parvus = Latin for “small” – indicates a reduced systolic peak velocity
This waveform pattern is commonly seen distal to a significant arterial stenosis and is an important Doppler ultrasound finding in vascular assessments.
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