Liver sonography

Liver sonography — Table of Contents (Topic-wise)

Contents (Topic-wise)

Purpose and Clinical Relevance

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Indications for Liver Ultrasound

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Normal Liver Size Chart by Age/Gender

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Lobes US Anatomy

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Segments US Anatomy

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Diaphragm Thickness Assessment

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Hepatic Artery Doppler Anatomy

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Portal Vein Ultrasound Anatomy

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Hepatic Veins Ultrasound Anatomy

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Biliary System Anatomy

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Polycystic Liver Disease (PCLD)

Liver shows multiple well-defined anechoic cysts of varying sizes scattered throughout the parenchyma, with posterior acoustic enhancement and no internal vascularity, features consistent with PCLD

Polycystic Liver Disease (PCLD)

Liver shows multiple well-defined anechoic cysts of varying sizes scattered throughout the parenchyma, with posterior acoustic enhancement and no internal vascularity, features consistent with PCLD.

Polycystic Liver Disease (PCLD) Type I

Liver showing posterior acoustic enhancement without internal septations, solid components, or mural nodules. No distortion of hepatic architecture or compression of vascular structures noted. Features are consistent with Polycystic Liver Disease – Type I.

Polycystic Liver Disease (PCLD) Type II

Multiple cysts with distortion of hepatic architecture — PCLD Type II.

Polycystic Liver Disease (PCLD) Type III

Extensive cystic involvement with gross distortion and hepatomegaly — PCLD Type III.

Congenital Hepatic Fibrosis (CHF)

Hepatomegaly with increased periportal echogenicity and irregular fibrotic bands — suggestive of CHF.

Caroli Disease

Multiple cystic/dilated intrahepatic bile ducts communicating with the biliary tree (central dot sign) — Caroli disease.

Simple Caroli Disease

Multiple cystic, tubular intrahepatic structures communicating with bile ducts (central dot sign) — simple Caroli disease.

Caroli Syndrome

Intrahepatic bile duct dilatations with periportal fibrosis/portal hypertension — Caroli syndrome.

Aberrant Hepatic Veins / Accessory Fissures

Anomalous course of hepatic veins with variant drainage.

Hepatic Simple cyst

Well-defined anechoic cystic lesion with smooth, thin walls in the liver; shows posterior acoustic enhancement and no internal septations, nodules, or vascularity — consistent with a simple hepatic cyst. Measures 23x31mm in diameter.

Beaver Tail Liver

Left hepatic lobe elongated, wrapping along the spleen — normal anatomical variant.

Hydatid Cyst (Cystic Echinococcosis) Stage – CE1

Liver shows a well-defined anechoic cyst with double wall sign, consistent with hydatid cyst (CE1).

Daughter cysts (Rosette Appearance) (CE2)

Multiloculated hepatic cyst with multiple peripheral daughter cysts arranged in a rosette pattern, suggestive of hydatid cyst (CE2 stage).

Multivesicular / Septated Cyst (Cartwheel sign or Honeycomb appearance) (CE2)

Cystic lesion with multiple internal septations and daughter cysts arranged in a cartwheel / honeycomb pattern, suggestive of multivesicular hydatid cyst (CE2).

Cyst with Detached Membrane (Water-lily sign) (CE3a)

Well-defined cystic lesion in the liver showing internal floating membranes (‘water-lily sign’), suggestive of hydatid cyst with detached endocyst.

Hydatid cyst (Serpent Sign) (CE3a)

Cystic lesion in the liver with floating wavy undulating membranes (‘serpent sign’), suggestive of hydatid cyst with detached endocyst.

Cyst with Solid Matrix & Daughter Cysts (Ball of wool sign) (CE3b)

Cystic lesion with heterogeneous solid matrix containing multiple daughter cysts, showing ‘ball of wool’ appearance, suggestive of hydatid cyst (transitional stage, CE3b).

Cyst with Snowstorm / Hydatid Sand (CE4)

Liver shows a well-defined cystic lesion with internal echogenic mobile echoes producing a ‘snowstorm / hydatid sand’ appearance, suggestive of Hydatid Cyst (CE4).

Hydatid cyst (Eggshell Calcification) (CE5)

Well-defined hepatic cyst with thick, curvilinear peripheral wall calcification (‘eggshell calcification’), suggestive of inactive hydatid cyst / calcified cyst (CE5 stage).

Pyogenic Liver Abscess

Complex cystic lesion with internal echoes/septations and peripheral vascularity — pyogenic abscess.

Amoebic Liver Abscess

Solitary hypoechoic lesion with low-level echoes, absent internal vascularity — amoebic abscess.

Candidiasis Microabscess Stage

Multiple tiny hypoechoic target-like lesions — hepatic candidiasis.

Candidiasis Chronic Stage

Multiple hypoechoic to hyperechoic nodules with calcifications — chronic hepatic candidiasis.

Candidiasis Diffuse Involvement

Innumerable small target-like hypoechoic lesions in a miliary pattern — disseminated candidiasis.

Hepatic Tuberculosis Micronodular (Miliary) Form

Hepatomegaly with multiple tiny (<2 mm) hypoechoic nodules; few isoechoic/hyperechoic — miliary hepatic TB.

Hepatic Tuberculosis Macronodular (Nodular/Tuberculoma) Form

Focal macronodular lesions (>2 cm), variable echogenicity; some liquefaction — tubercular involvement.

Hepatic Tuberculosis (Miliary) Form

Hepatomegaly with multiple tiny (<2 mm) hypoechoic nodules; some with central caseation and necrosis — miliary hepatic TB.

Acute Viral Hepatitis

Liver is enlarged with hypoechoic parenchyma and accentuated periportal echogenicity (‘starry sky’ sign). Features suggestive of acute viral hepatitis.

Chronic Viral Hepatitis

Liver shows mild hepatomegaly with coarse parenchymal echotexture. Portal tracts appear echogenic. Features consistent with chronic viral hepatitis.

Perihepatitis / Fitz-Hugh-Curtis Syndrome

Liver parenchyma appears normal. Hepatic capsule shows thickening with subtle perihepatic fluid/adhesions. Features are suggestive of perihepatitis (Fitz-Hugh-Curtis Syndrome) in the setting of pelvic inflammatory disease.

Diffuse hepatic steatosis Grade-i (Fatty liver)

Increased echogenicity with posterior attenuation; blunted portal margins.

Diffuse hepatic steatosis Grade-ii (Fatty liver)

Increased echogenicity with attenuation and blurring of portal/hepatic vein margins.

Diffuse hepatic steatosis Grade-iii (Fatty liver)

Marked echogenicity with poor diaphragm/vessel visualization due to attenuation.

Non-alcoholic fatty liver disease

Diffuse increased echogenicity with attenuation and blurring of vessel margins (NAFLD).

Focal hepatic fat (Focal hepatic steatosis)

Focal increased echogenicity without mass effect; vessels traverse normally.

Nodular focal fat sparing

Well-defined hypoechoic area without mass effect; normal vessels through it.

Multifocal fatty liver deposition/Multifocal nodular hepatic steatosis

Multiple hyperechoic nodules without mass effect; preserved vascular architecture.

Autoimmune Hepatitis

Liver is enlarged with coarse echotexture and periportal hyperechogenicity. Findings may be suggestive of autoimmune hepatitis; correlation with serology advised.

Glycogen Storage Disease

Marked hepatomegaly with increased echogenicity; homogeneous texture — GSD.

Type I – Von Gierke Disease

Hepatomegaly with diffuse echogenicity — GSD Type I.

GSD Type II – Pompe Disease

Echogenic liver ± cardiomegaly — GSD Type II.

GSD Type III – Cori / Forbes Disease

Enlarged echogenic coarse liver — GSD Type III.

GSD Type IV – Andersen Disease

Coarse, heterogeneous echotexture with fibrosis/cirrhosis features — GSD IV.

GSD Type V – McArdle Disease

Normal liver sonographically; muscle changes may be seen — GSD V.

GSD Type VI – Hers Disease

Mild–moderate hepatomegaly with homogeneous increased echogenicity — GSD VI.

GSD Type VII – Tarui Disease

No significant hepatic abnormality; muscle findings may be present — GSD VII.

GSD Type IX – Phosphorylase Kinase Deficiency

Hepatomegaly with diffusely echogenic parenchyma — GSD IX.

GSD Type 0 (Hepatic Glycogen Synthase Deficiency)

Normal sonographic liver; correlate clinically — GSD 0.

Amyloidosis

Hepatomegaly with diffusely heterogeneous increased echogenicity.

Hemochromatosis

Hepatomegaly with diffusely increased echogenicity; coarse texture.

Wilson Disease

Coarse heterogeneous liver, increased echogenicity, irregular margins — chronic disease.

Stag head sign (Dilated IVC and hepatic veins)

The short axis view of the IVC and the hepatic veins show dilation: measures of 29 mm IVC & 15 mm main hepatic vein dilation. Features are compatible with Stag head sign. Oblique subxiphoid window showing pleural anechoic collection compatible with right pleural effusion.

Portal Vein Thrombosis

Echogenic thrombus with cavernoma and periportal collaterals — chronic PVT.

3-Budd-Chiari Syndrome

HV/IVC thrombus with reduced/absent flow; hepatomegaly; heterogeneous parenchyma.

Congestive Hepatopathy

Hepatomegaly with coarse texture; dilated hepatic/portal veins; loss of venous phasicity.

Portal Hypertension

Dilated PV with reduced hepatopetal flow; splenomegaly; collaterals.

Focal Arteriovenous Malformation

High-velocity, low-resistance arterial flow with early venous filling — AVM.

Hepatic Arteriovenous Malformation

Multiple anechoic channels with turbulent color flow; arterialized venous waveforms.

Echogenic Hemangioma

Well-defined, homogeneously hyperechoic lesion with enhancement; no internal Doppler flow.

Hypoechoic Hemangioma

Well-defined hypoechoic lesion with enhancement; minimal/no internal Doppler flow.

Heterogeneous Hemangioma

Predominantly hyperechoic lesion with enhancement; peripheral Doppler flow — atypical; consider CE imaging.

Hepatocellular Carcinoma HCC (single lesion)

Heterogeneous lesion with irregular margins and internal vascularity HCC.

Hepatocellular Carcinoma HCC (multiple lesion)

Multiple heterogeneous lesions with arterial vascularity on chronic liver background — multifocal HCC.

HCC PV invasion suspected

Portal vein tumor thrombus with internal arterial flow HCC.

Hepatic Adenoma

Well-circumscribed lesion; variable echogenicity; minimal vascularity — adenoma.

Focal Nodular Hyperplasia (FNH)

Well-circumscribed homogeneous lesion; central Doppler vascularity — FNH likely; consider CE imaging.

Echogenic Metastases

Multiple confluent hyperechoic nodules — metastases.

Hypoechoic Metastases

Numerous hypoechoic nodules — metastases.

Chronic Active Hepatitis → Cirrhosis Progression

Acute hematoma

Poorly defined hyperechoic/heterogeneous area — acute hematoma.

Organizing hematoma

Well-defined hypoechoic to complex cystic lesion with septations/debris — subacute hematoma.

Chronic hematoma

Encapsulated hypo/anechoic lesion with residual echoes — chronic resolving hematoma.

Liver Laceration

Irregular linear hypoechoic defect with perihepatic fluid — laceration.

Subcapsular Hemorrhage

Hyperechoic subcapsular collection indenting surface — acute subcapsular hematoma.

Hepatomegaly

Liver is enlarged in size with rounded inferior margin. Parenchymal echotexture is homogeneous with normal echogenicity. No focal lesion is identified. Intrahepatic biliary radicles are not dilated. Portal vein and hepatic veins are patent with normal flow.

Heterogeneous lesion

Coarse echotexture (? Chronic Liver Diseases)

Liver shows coarse, heterogeneous echotexture with irregular parenchymal pattern. No focal SOL identified. Findings are suggestive of chronic parenchymal liver disease.

Chronic liver failure/Liver cirrhosis

Liver shows increased parenchymal echogenicity with coarse echotexture (fatty fibrotic pattern) and decreased definition of the portal vein wall. Features are suggestive of chronic liver disease / chronic liver failure or cirrhosis.

Acute liver failure

Liver shows irregular contour with diffuse heterogeneity of parenchymal echotexture giving a starry night appearance, along with posterior sound attenuation. Multiple ubiquitous hyperechoic and hypoechoic micro- and macronodules are noted. These features are compatible with fulminant hepatic failure.

Atrophy of Liver Segment

Volume loss and parenchymal thinning of [segment] — segmental atrophy.

Regenerative Nodules

Multiple small iso–mildly hypoechoic nodules on coarse background — regenerative nodules.

Post-Surgical/Transplant Changes type-i

Localized parenchymal atrophy with architectural distortion — post-surgical change.

Post-Surgical/Transplant Changes type-ii

Linear echogenic bands/scar — post-operative changes.

Post-Surgical/Transplant Changes type-iii

Well-defined adjacent fluid collection — post-surgical seroma/hematoma.

Focal SOL (indeterminate)

Right lobe of liver shows a focal heterogeneous lesion of indeterminate nature. Margins are ill-defined. No definite internal calcification or cystic change noted. Color Doppler shows minimal/absent internal vascularity. Features are indeterminate; recommend further evaluation with contrast-enhanced CT/MRI for characterization.