Diagnostic Sonography • Case Study Atlas
Diffuse Hepatic Steatosis
A structured ultrasound case collection covering diffuse hepatic steatosis from Grade 1 mild steatosis through Grade 2 moderate steatosis and Grade 3 severe steatosis, with sonographic morphology, reporting, impression, recommendations and learning points.
Case Index
01
Diffuse Hepatic Steatosis – Grade 1
→
02
Diffuse Hepatic Steatosis – Grade 2
→
03
Diffuse Hepatic Steatosis – Grade 3
→
Chapter 01 • Case Study
Diffuse Hepatic Steatosis – Grade 1
Mild Hepatic Steatosis01 Clinical History
A patient presents for abdominal ultrasound evaluation.
The liver is mildly increased in echogenicity compared
with the renal cortex. Hepatic architecture is preserved,
and the portal vein walls and diaphragm remain relatively
well visualized.
02 Ultrasound Image
03 Ultrasound Morphology
| Feature | Sonographic Description |
|---|---|
| Liver Echogenicity | Mild diffuse increase in hepatic parenchymal echogenicity compared with the renal cortex. |
| Parenchymal Pattern | Relatively homogeneous increased echogenicity without a focal hepatic lesion. |
| Portal Vein | Portal venous radicles and walls remain relatively well visualized. |
| Hepatic Veins | Hepatic veins are generally visualized. |
| Diaphragm | Diaphragmatic outline remains well visualized. |
| Focal Lesion | No focal hepatic lesion identified on the provided examination. |
| Associated Findings | Assess liver size, contour, gallbladder, biliary tree, spleen and portal venous system as clinically indicated. |
04 Ultrasound Report
The liver is mildly enlarged, measuring approximately 155 mm at the midclavicular line (MCL).
There is diffuse mild increase in hepatic echogenicity compared with the right renal cortex,
consistent with Grade I hepatic steatosis (fatty liver). Mild posterior beam attenuation is noted,
with preserved visualization of the intrahepatic vessels and diaphragm.
No focal hepatic lesion or intrahepatic biliary dilatation is identified.
The portal vein is normal in caliber, with normal hepatopetal flow on Color Doppler.
05 Impression
Sonographic Impression
Mild diffuse hepatic steatosis
(Grade 1 fatty liver).
06 Recommendation
Correlate with clinical and laboratory findings.
Consider assessment of metabolic risk factors and
appropriate clinical follow-up. Ultrasound grading
of steatosis should be interpreted in conjunction
with the clinical context.
07 Learning Points
Recognize mild diffuse increase in hepatic
echogenicity compared with the renal cortex.
Portal vein walls and intrahepatic vascular
structures remain relatively well visualized.
The diaphragm is usually still clearly visualized
in mild steatosis.
Always assess the liver for focal lesions and
associated hepatobiliary abnormalities.
Chapter 02 • Case Study
Diffuse Hepatic Steatosis – Grade 2
Moderate Hepatic Steatosis01 Clinical History
A 45-year-old patient was referred for abdominal ultrasound due to abnormal liver function tests, obesity, diabetes mellitus, dyslipidemia, metabolic syndrome, or incidental fatty liver detected on previous imaging. The patient may be asymptomatic or complain of mild right upper quadrant discomfort or fatigue.
02 Ultrasound Image
03 Ultrasound Morphology
| Feature | Sonographic Description |
|---|---|
| Liver Echogenicity | Moderate diffuse increase in hepatic parenchymal echogenicity. |
| Parenchymal Pattern | Diffusely echogenic hepatic parenchyma with increased attenuation of the ultrasound beam. |
| Portal Vein | Visualization of portal venous radicles and their walls is reduced compared with normal. |
| Hepatic Veins | Hepatic venous structures may be less distinct because of increased parenchymal echogenicity. |
| Diaphragm | Diaphragmatic visualization may be partially reduced because of beam attenuation. |
| Focal Lesion | No focal hepatic lesion identified on the provided examination. |
| Associated Findings | Assess liver size, contour, portal vein, spleen, gallbladder and biliary tree. |
04 Ultrasound Report
The liver is enlarged, measuring approximately 155 mm at the midclavicular line (MCL). Diffuse moderate increase in hepatic echogenicity is noted compared with the right renal cortex, consistent with Grade II hepatic steatosis (fatty liver). Moderate posterior beam attenuation is present with mildly reduced visualization of the intrahepatic vessels and diaphragm. No focal hepatic lesion or intrahepatic biliary dilatation is identified. Portal venous flow is normal on Color Doppler imaging.
05 Impression
Sonographic Impression
Moderate diffuse hepatic steatosis
(Grade 2 fatty liver).
06 Recommendation
Correlate with clinical history, body habitus,
metabolic risk factors and liver biochemical
profile. Further assessment may be considered
when clinically indicated, particularly if there
are risk factors for chronic liver disease.
07 Learning Points
Moderate steatosis produces more pronounced
hepatic echogenicity than Grade 1 steatosis.
Portal venous walls and intrahepatic vascular
structures become less clearly visualized.
Increased posterior attenuation may reduce
visualization of deeper hepatic structures.
Evaluate the liver systematically and assess
associated hepatobiliary structures.
Chapter 03 • Case Study
Diffuse Hepatic Steatosis – Grade 3
Severe Hepatic Steatosis01 Clinical History
A patient presents for abdominal ultrasound
evaluation. The liver demonstrates marked diffuse
increase in echogenicity with substantial beam
attenuation and poor visualization of the deeper
hepatic structures, intrahepatic vessels and
diaphragm.
02 Ultrasound Image
03 Ultrasound Morphology
| Feature | Sonographic Description |
|---|---|
| Liver Echogenicity | Marked diffuse increase in hepatic parenchymal echogenicity. |
| Parenchymal Pattern | Very echogenic hepatic parenchyma with substantial attenuation of the ultrasound beam. |
| Portal Vein | Intrahepatic portal venous branches are poorly visualized because of marked echogenicity and attenuation. |
| Hepatic Veins | Hepatic venous structures may be poorly visualized in the deeper liver. |
| Diaphragm | Diaphragmatic outline is poorly or incompletely visualized. |
| Posterior Attenuation | Pronounced attenuation of the ultrasound beam with poor penetration into the deep liver. |
| Focal Lesion | Assessment for focal lesions may be limited by marked attenuation; document limitations when applicable. |
| Associated Findings | Assess liver contour, portal venous system, spleen, gallbladder and biliary tree as clinically appropriate. |
04 Ultrasound Report
The liver is enlarged, measuring approximately 155 mm at the midclavicular line (MCL). There is marked diffuse increase in hepatic echogenicity compared with the right renal cortex, consistent with Grade III hepatic steatosis (fatty liver). Marked posterior acoustic beam attenuation is present with poor visualization of the intrahepatic vessels and diaphragm. No focal hepatic lesion or intrahepatic biliary dilatation is identified. Portal venous flow is normal on Color Doppler imaging.
05 Impression
Sonographic Impression
Severe diffuse hepatic steatosis
(Grade 3 fatty liver) with marked posterior
acoustic attenuation.
06 Recommendation
Correlate with clinical history and laboratory
findings. Consider further evaluation when
clinically indicated, particularly where there
are risk factors for chronic liver disease or
when ultrasound visualization is substantially
limited by steatosis.
07 Learning Points
Grade 3 steatosis is characterized by marked
hepatic echogenicity and substantial beam
attenuation.
Deep hepatic structures and intrahepatic vessels
may become poorly visualized.
The diaphragm may be poorly visualized because
of significant posterior attenuation.
Severe steatosis can limit detection and
characterization of focal hepatic abnormalities;
document technical limitations when present.
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