Technical Assessment for Liver Ultrasound

Technical Assessment for Liver Ultrasound

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A comprehensive technical assessment ensures optimal image quality, proper anatomical visualization, and accurate documentation. It includes evaluation of study type, image quality, and key anatomical structures such as liver contour, parenchyma, biliary tree, and adjacent organs. The assessment guides radiologists in diagnosing hepatic pathology accurately and consistently.
Transducer Selection The selection of the ultrasound transducer is crucial for achieving optimal liver imaging:

• Curved Array Transducer (2–5 MHz): Standard probe for abdominal imaging, offering deep penetration and wide field of view.
• Linear Array Transducer (5–12 MHz): Suitable for superficial lesions and guiding interventional procedures.
• Phased Array Transducer: Useful in intercostal imaging and in patients with limited acoustic windows (e.g., ICU patients).

Machine Settings and Optimization Proper machine settings are essential for clear visualization:

• Depth: Adjusted to include the entire liver, including posterior segments.
• Gain and TGC: Balanced for uniform brightness across the liver field.
• Focus: Positioned at or just below the region of interest.
• Dynamic Range: Moderate setting for better tissue contrast and detail.
• Harmonic Imaging: Enhances image clarity by reducing artifacts.

Doppler and Elastography Considerations

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For vascular assessment, Doppler settings must be optimized:

• Color Doppler: Adjust PRF and wall filter based on hepatic vessel velocity.
• Spectral Doppler: Use angle correction ≤60° to assess flow direction and waveform.
• Elastography: Perform in the right lobe intercostally, avoiding large vessels; patient should hold breath during acquisition for accurate liver stiffness measurement.

Descriptive Terminology for Liver Ultrasound

Descriptive Terminology for Liver Ultrasound

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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:

• the renal cortex (of the right kidney)
• and usually also slightly brighter or equal to the spleen.

Increased echogenicity Suggests fatty infiltration (hepatic steatosis).
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 br="" mm="" post-cholecystectomy="" pre-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.

Liver Ultrasound: Measurements and Interpretation
1. Liver Size
2. Common Bile Duct (CBD)
3. Portal Vein
4. Hepatic Veins and Artery
5. Spleen Size (For portal hypertension evaluation)
6. Ascites
7. Liver Lesions (Measurement & Description)
8. Liver Surface Nodularity
9. Parenchymal Texture

Jujment of liver Lesions/Masses on ultrasound

Jujment of liver Lesions/Masses on ultrasound

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Lesions/Masses: Presence of any focal lesions (e.g., cysts, hemangiomas, metastases) – describe size, location, echogenicity, borders, vascularity (with Doppler).
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

Anechoic Lesion

• Appearance: Well-defined, black with posterior enhancement
• Examples: Simple cyst, biliary cyst
• Significance: Typically benign

Hypoechoic Lesion

• Appearance: Darker than liver, poorly marginated or irregular
• Examples: Liver abscess, metastases, early HCC, lymphoma
• Significance: Needs Doppler/CEUS/biopsy for confirmation

Isoechoic Lesion

• Appearance: Same echogenicity as liver → “invisible” on grayscale
• Examples: HCC, hemangioma (sometimes)
• Tips: Look for capsular bulge, distortion, or use Doppler/CEUS

Hyperechoic Lesion

• 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

Mixed Echogenic Lesion

• Appearance: Irregular internal echoes, septations, solid + cystic parts
• Examples: Necrotic metastases, hepatoblastoma, complex abscess
• Red Flag: Always needs further investigation

Clinical Interpretation Table

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
Assessment of lesion borders on ultrasound is a crucial component in the evaluation of liver pathology. The morphology and definition of lesion margins offer valuable diagnostic insights that help distinguish between benign and malignant entities.

• Well-defined, smooth borders typically indicate benign lesions, such as simple cysts or hemangiomas.

• Shape & Echogenicity: Hemangiomas often appear as small (<3 against="" bright="" clearly="" cm="" hyperechoic="" lesions="" li="" liver="" out="" parenchyma.="" stand="" the="" these="" uniformly="">
• 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.

Image 1: Small HCC (<2 a="" around="" capsule="" cm="" fibrous="" halo="" hypoechoic="" nodule="" presenting="" represents="" rim="" t="" the="" thin="" this="">

Image 2: Larger HCC with a distinct peripheral halo—along with lateral shadow and posterior enhancement, these features are hallmark ultrasound signs of HCC >20 mm

Image 3: show a heterogeneous hypoechoic lesion with a thin rim—readers will notice the halo and accompanying mosaic pattern typical of HCC.

Image 4: A heterogenous lesion with a clear hypoechoic rim (halo sign) observed in a cirrhotic liver—both B‑mode and color Doppler confirm the classic halo morphology.
• Thickened, nodular, or multiloculated borders may point toward necrotic tumors, abscesses, or parasitic cysts like hydatid disease.

Image 1: Complex sonographic pattern in a suspected malignant focal liver lesion. The thick irregular rim surrounds a heterogeneous center, suggesting necrosis and solid tumor components. Image 2: A large multilocular cystic mass with thick walls and internal heterogeneity, highly suggestive of abscess or necrotic tumor.
• Capsular bulging suggests mass effect and is often seen in large or exophytic 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

Jujment of liver Contour on ultrasound

Jujment of liver Contour on ultrasound

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Contour: Smooth / Irregular / Nodular.

Jujment of liver Echogenicity on ultrasound

Jujment of liver Echogenicity on ultrasound

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Echogenicity: Normal / Increased / Decreased.

Jujment of liver Echotexture on ultrasound

Jujment of liver Echotexture on ultrasound

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Echotexture: Normal / Increased (suggestive of fatty infiltration) / Heterogeneous (suggestive of cirrhosis or other pathology).

Jujment of liver size on ultrasound

Jujment of liver size on ultrasound

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Size: Normal / Enlarged / Reduced (e.g., liver length at midclavicular line: XX cm).

Standard Patient Positions and scaning plans for liver ultrasound

Standard Patient Positions

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In liver ultrasound imaging, different scanning planes are used to comprehensively evaluate the liver's anatomy, vasculature, and any pathological changes. Here’s a concise overview of the scanning planes in liver ultrasound:
1. Transverse (Axial) Plane

• Orientation: The transducer is placed horizontally across the upper abdomen.
• View:Cross-sectional view of the liver.
• Structures Visualized:
• Right and left lobes of the liver.
• Portal vein in its transverse section ("Mickey Mouse sign").
• Gallbladder (if included).
• Inferior vena cava (IVC).

2. Sagittal (Longitudinal) Plane

• Orientation:The transducer is oriented vertically along the midline or right upper quadrant.
• View: Longitudinal view of the liver.
• Structures Visualized:
• Liver span (craniocaudal length).
• Relationship to the kidney (e.g., "liver-kidney interface").
• IVC in longitudinal section.

3. Subcostal Plane

• Orientation:Transducer is angled upward under the costal margin.
• Use:Often used in deep inspiration to improve liver visualization by moving the liver below the rib cage.
• Structures Visualized:
• Anterior liver segments.
• Hepatic veins and diaphragm.

4. Intercostal Plane

• Orientation:Transducer is placed between the ribs in the right upper quadrant.
• Use:Helps avoid rib shadows.
• Structures Visualized:
• Superior liver segments.
• Diaphragmatic surface.
• Right hepatic lobe.

5. Coronal Plane

• Orientation: Transducer placed in the mid or anterior axillary line, scanning vertically.
• View: Vertical slice from side to side.
• Structures Visualized:
• Lateral and medial segments.
• Hepatic veins draining into the IVC.

6. Oblique Planes

• Orientation:Angled transducer positioning tailored to follow vascular pathways or segmental anatomy.
• Use:For targeted views of:
• Portal vein bifurcation.
• Hepatic veins.
• Lesions.

Key Tips for Liver Ultrasound Scanning

• Patient Position:Supine, left lateral decubitus, or upright to optimize visualization.
• Breathing Technique: Deep inspiration enhances liver window by displacing the liver downward.
• Acoustic Window:Use the right kidney or full bladder (if scanning caudally) as acoustic windows.

Neurenteric cyst

Neurenteric cyst

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Figer-1

📄 Report Sample Line- Neurenteric cyst
A well-defined, anechoic cystic lesion [70x35x30 mm] extended from the right hemidiaphragm to the posterior mediastinum and left lung apex (adjacent to the spine ) and contained clear mucoid material. It formed no attachments to trachea. vertebral column. esophagus. or sub- diaphragmatic bowel.


Conclussion: 📋 Neurenteric cyst
Recommendation: Further evaluation with MRI is recommended for detailed anatomical correlation.

Retained product of conception [RPOC] ultrasound case study

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Case Study
Retained product of conception [RPOC]

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Clinical History: The patient is a [22]-year-old [female] presenting with a history of recent miscarriage/delivery [12 days ago].
Figer-1

📄 Report Sample Line- Retained product of conception [RPOC]
Shows 30x16 mm irregular, heterogeneous echogenic material within the endometrial cavity, without a distinct gestational sac or fetal parts. Endometrial thickness is increased, and vascularity may be seen on Doppler, suggestive of retained products of conception. The cervical os may be open or closed.


Conclussion: 📋 Retained product of conception [RPOC].
Recommendation: Serial β-hCG and clinical monitoring.

Ovarian follicular cyst ultrasound case study

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Case Study
Ovarian follicular cyst

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Clinical History: The patient is a [32]-year-old [female] presenting with intermittent lower abdominal pain and pelvic discomfort that has been ongoing for the past [3 time period]. The pain is described as dull and crampy, primarily on the right/left side of the abdomen, and tends to occur around ovulation or the menstrual cycle. The pain has been mild but is noticeable during daily activities and sometimes worsens with physical exertion.
Figer-1

📄 Report Sample Line- Ovarian follicular cyst
A unilocular cyst is noted in the right/left ovary, measuring approximately [19x20xmm]. The cyst appears anechoic with smooth, well-defined borders, which is characteristic of a simple ovarian follicular cyst. There is no evidence of internal septations, solid components, or vascularity within the cyst, suggesting it is non-complex.


Conclussion: 📋 Ovarian follicular cyst
Recommendation: Follow-up ultrasound is recommended in [time frame, 6-8 weeks] to monitor for any changes in size or resolution of the cyst.

Corpus luteum cyst ultrasound case study

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Case Study
Corpus luteum cyst

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Clinical History: The patient is a [25]-year-old [female] presenting with lower abdominal discomfort and mild pelvic pain.
Figer-1

📄 Report Sample Line- Corpus luteum cyst
A unilocular cyst is identified in the left ovary, measuring approximately [13x14 mm]. The cyst is located in the ovarian luteal phase, with thickened walls and anechoic fluid. The cyst contains normal peripheral vascularity (ring of fire), which is characteristic of a corpus luteum cyst.


Conclussion: 📋 Corpus luteum cyst
Recommendation: Follow-up ultrasound may be considered in [time frame, 6-8 weeks] to monitor for spontaneous resolution, as corpus luteum cysts typically resolve on their own.

Simple ovarian cyst ultrasound case study

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Case Study
Simple ovarian cyst

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Clinical History: The patient is a [30]-year-old [female] presenting with pelvic discomfort and mild lower abdominal pain. The pain is described as dull and intermittent, with no associated nausea, vomiting, or fever. The patient denies any changes in menstrual cycle, but reports irregular periods in the past few months.
Figer-1

📄 Report Sample Line- Simple ovarian cyst
A unilocular cyst is identified in the ovary, measuring approximately [___ mm/cm]. The cyst has smooth, well-defined borders and is filled with anechoic fluid consistent with a simple ovarian cyst


Conclussion: 📋 Simple ovarian cyst
Recommendation: Clinical corelation is required

Diffuse hepatic steatosis [Fatty liver grade-1]

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Case Study
Diffuse hepatic steatosis [Fatty liver grade-1]

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Clinical History: The patient presents with a history of mild fatigue and right upper quadrant discomfort. There is no significant history of alcohol abuse. The patient has a history of overweight/obesity and has not been following a healthy diet or regular exercise regimen.
Figer-1

📄 Report Sample Line- Diffuse hepatic steatosis [Fatty liver grade-1]
The liver is enlarged with uniform increase in echogenicity, suggesting diffuse fatty infiltration.


Conclussion: 📋 Diffuse hepatic steatosis [Fatty liver grade-1]
Recommendation: Clinical corelation is requered

Enteritis ultrasound case study

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Case Study
Enteritis

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Clinical History: 00
Figer

📄 Report Sample Line- Enteritis
The bowel loops show thickening of the wall, particularly in the distal ileum. The wall thickness is increased to approximately [___ mm], consistent with active inflammation.Peristalsis appears normal, but there is mild hyperechogenicity of the surrounding fat, suggesting edema


Conclussion: 📋 Enteritis
Recommendation: Clinical correlation is requared