Definition — Liver Calcification (Hepatic Calcification): Deposition of calcium salts within the hepatic parenchyma or within focal hepatic lesions. Calcifications may be dystrophic (in necrotic or treated tumours), granulomatous (healed infection), parasitic, vascular, or related to prior surgery/trauma. Sonographically calcifications appear as brightly echogenic foci; large calcifications cast posterior acoustic shadowing while tiny microcalcifications may create comet-tail or reverberation artifacts.
Sonographic features — Liver Calcification:
- Appearance: Bright echogenic foci within the liver parenchyma or within lesions. Dense calcifications produce strong posterior acoustic shadowing; microcalcifications may cause comet-tail/reverberation artifacts.
- Location & distribution: Solitary or multiple; segmental, lobar or diffuse distribution. Note relation to bile ducts, vessels, prior surgical sites or focal lesions.
- Associated lesion: Calcification within a mass may indicate dystrophic change (treated or necrotic tumour), healed abscess, hydatid cyst (inactive), or calcified metastasis (eg mucinous primaries).
- Doppler: Calcified foci are avascular; assess surrounding tissue for increased vascularity which may indicate active inflammation or viable tumour.
- Acoustic shadowing vs enhancement: Dense calcifications cast shadowing; biliary or gas artifacts may mimic shadowing — correlate with patient history and other imaging.
- Comet-tail/reverberation: Typical of small intraparenchymal calcifications or biliary microstones and helpful to distinguish from surgical clips or gas.
- Mimics: Surgical clips, gallstones in an intrahepatic duct, phleboliths, gas — cross-check prior imaging (CT/X-ray) to confirm true calcification.
- Clinical relevance: Calcification usually indicates chronicity/healing. New calcification within a lesion requires further characterisation to exclude treated tumour vs progressing disease.
- Reporting tips: Document number, size, segmental location (Couinaud), presence/absence of posterior shadowing, relation to adjacent structures, and comparison with prior imaging.
Case Study — 1: Hepatic Calcification/Solitary Calcified Granuloma:
48-year-old female with intermittent right upper quadrant discomfort. No fever. History of prior pulmonary tuberculosis.
Ultrasound:
Single 10–12 mm intensely echogenic focus in segment IV with posterior acoustic shadowing; no surrounding hypoechoic halo, no internal vascularity.
Interpretation:
Appearance most consistent with a healed calcified granuloma. Recommend correlation with prior chest imaging and clinical history; no evidence of active infection or viable tumour on ultrasound.
Ultrasound Report — Line
Liver shows a solitary 12.22 mm echogenic focus in segment IV with strong posterior acoustic shadowing — appearance consistent with hepatic calcification/old granuloma. No adjacent mass or intra-lesional vascularity identified. Background liver echotexture within normal limits. Recommend correlation with prior CT or radiographs to confirm chronicity.
Conclusion
Focal hepatic calcification in segment IV, most likely a healed granuloma. No sonographic evidence of active abscess or viable tumour.
Recommendation
- Correlate with prior imaging (non-contrast or contrast CT) to confirm calcific density and chronicity.
- If calcification is new or associated with a mass, obtain contrast-enhanced CT for full characterisation.
- If infection suspected clinically (fever, raised inflammatory markers), consider CT and clinical management; aspiration only if abscess suspected and accessible.
Right kidney shows A tiny echogenic foci in the mid calyx , consistent with microlithiasis. No significant hydronephrosis noted.
Left kidney demonstrates a single echogenic calculus measuring ~3.7 mm in the mid calyx with posterior acoustic shadowing and twinkle artifact on Doppler. No associated hydronephrosis observed.
Causes / Etiology
- Healed granulomatous infections (tuberculosis, histoplasmosis).
- Healed pyogenic liver abscess.
- Dystrophic calcification in treated or necrotic tumours.
- Parasitic infections (inactive hydatid cysts may calcify).
- Surgical clips, prior trauma, or hemorrhage.
- Calcified metastases (particularly mucinous primaries).
Symptoms / Clinical features
- Most hepatic calcifications are asymptomatic and incidental findings.
- If due to active abscess — RUQ pain, fever, leukocytosis and raised CRP.
- Mass effect symptoms only when associated with large lesion.
Diagnostic Strategy
- Identify echogenic focus and characterise artifact (shadowing vs comet-tail).
- Use Doppler to confirm lack of internal vascularity.
- Compare with prior imaging (CT or radiographs) — CT is gold standard to confirm mineral density.
- If infection suspected, correlate with labs (CBC, CRP) and treat/aspirate as indicated.
Risk Factors
- History of granulomatous disease or endemic infections.
- Prior hepatic abscess, parasitic disease, or liver trauma.
- Prior hepatic tumour treatment (ablation, chemo) leading to dystrophic calcification.
- Metastatic disease from calcifying primaries (less common).
Declaration:
I, R. K. Mouj, declare that the material presented in this document titled "Liver Calcification — Sonographic Guide" has been prepared for educational purposes. Patient data should be anonymised and clinical correlation is required.
Author: ____________________
Name: R. K. Mouj [Radio-imaging Technologist]
Supervisor / Guide: Department radiologist
Department: Radiology
Institution: ____________________
Date: 25-09-2025
"Every cyst tells a story — knowing the benign from the sinister is the art of ultrasound."
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