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Ultrasound in liver diseases

Geir Folvik, MD

Division of Gastroenterology

Department of Medicine, Haukeland University Hospital

Bergen, Norway

25. november 2019

Agenda

Benign liver diseases

– Benign focal liver lesions

– Fatty liver disease

– Liver cirrhosis

– Other benign liver disorders

Malignant liver diseases

– Hepatocellular carcinoma

– Cholangiocarcinoma

– Liver metastases

– Lymphoma

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Benign liver diseases

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Hemangioma

most common benign tumour of the liver (prevalence 5-10%)

small (< 2-3 cm)

– homogeneous

– hyperechogenic lesion

– well defined, often with irregular margins

– often found in a subcapsular or perivascular position

most often discovered by coincidence

larger hemangiomas can be atypical with heterogeneous echogenicity

typical vascular pattern

– peripheral nodular arterial enhancement followed by centripetal filling

contrast-enhanced ultrasonography(CEUS) and MRI > CT

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Hemangioma

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Hemangioma

typically peripheral nodular contrast

enhancement on CEUS

centripetal fill-in

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Focal nodular hyperplasia/ Adenoma

FNH– second most common benign liver tumour (incidence of 1-3%)

– most often discovered by coincidence

– often almost isoechoic with a central stellate scar

– non-encapsulated, but well defined

– typical centrifugal vascular filling to the periphery in the arterial phase on Color Doppler,CEUS, CT and MRI

Liver cell adenoma– adenomas less frequent than FNH

– encapsulated

– larger adenomas often inhomogeneous due to bleeding, necrosis and fibrosis

– RUQ pain due to mass effect or bleeding

– CEUS

– biopsy seldom indicated

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FNH

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FNH -CEUS

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FNH -CEUS

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Adenoma

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Adenoma

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Liver cysts

ultrasound is highly accurate in diagnosing liver cysts

anechoic with a clear posterior demarcation (but no wall)

posterior enhancement

often round in shape and smooth

occasionally RUQ pain due to mass effect or bleeding

polycystic liver disease– autosomal dominant disorder

– often multiple renal cysts (>50%)

– variation in size and shape

– hepatomegaly, cholestasis and portal hypertension (PHT)

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Liver cysts

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Liver cysts

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Polycystic liver disease

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Liver abscess

cystic pattern on ultrasound

spherical, oval or slightly irregular echo-poor lesions

often contain echogenic material including bubbles of gas

abscess wall more irregular than in simple cysts

fever, leucocytosis, CRP elevation and elevated LFT`s

ultrasound for percutaneous abscess drainage

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Liver abscess

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Liver abscess

CEUS

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Lipoma and Fatty liver disease

Lipoma– a highly reflective hyperechogenic tumour with sharp

demarcation (”very bright”)

Fatty liver disease– steatosis or diffuse fatty liver -hyperechogenic liver

– focal fatty infiltration -hyperechogenic area

– in ”focal sparing” you will find a hypoechogenic area or lesion in a diffuse fatty liver

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Lipoma -US og CT

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Fatty liver ALCOHOL

NAFLD (obesity/ DM/ hyperlipidaemia)

drugs/ toxic substances

TPN

pregnancy

malnutrition/ bypass surgery

inborn errors of metabolism (”metabolic” diseases)

hepatomegaly

hyperechogenic with fine, closely packed echoes/ ”bright liver”

blood vessels and diaphragm often less distinct

increased attenuation => reduced visualisation ”in depth”

sensitivity 80-100% (depends of severity)

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Focal fatty infiltration

hyperechogenic area

vessels are normal without displacement

no mass effect

can respect anatomical margins

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Steatosis

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Fatty liver with ”focal areas of sparing”

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Fatty liver with ”focal areas of sparing”

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Liver cirrhosis

ultrasonographic signs in more than 2/3 of cases

increased echogeneity (increased reflection due to fibrosis)

coarse and irregular echo-structure

portal vein walls often not defined

irregular contour because of surface nodularity -Lelio et al. Radiology 1989

– especially with high-frequency transducers and ascites

atrophy of the right lobe and hypertrophy of the caudate lobe

large regenerative nodules (DD: metastases/ tumours)

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Liver cirrhosis

hepatic veins: often flattened flow-curve

thickened and layered wall of the gallbladder

ascites (Morrison`s pouch)

portal hypertension (PHT)

– alteration in or reversal of portal vein flow

– portal vein diameter increase in size to > 13-15mm

– splenomegaly

– collaterals/ recanalized paraumbilical vein

increased risk of HCC

– US screening +/- AFP every 6-12 months?

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Liver cirrhosis

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Liver cirrhosis

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Enlarged caudate lobe

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Flow-curve of the hepatic veins

Cirrhosis

Normal

Portal hypertension

Dilated portal vein

Reversed flow in the portal vein Open umbilical vein

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Other benign disorders congestive liver failure

acute viral hepatitis

cholestatic liver disease

hematomas

regenerative nodules in cirrhosis

hydatid disease (echinococcal cysts)

amoebic abscess –hypoechogenic (history!)

schistosomiasis

Caroli`s disease

biloma (bile leakage)

granulomas usually not visualised

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Congestive liver failure

congestive heart failure

dilatation of the hepatic veins

dilatation of vena cava

– compression/ Valsalva

hepatomegaly

ascites

portal hypertension

ESLD

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PBC and PSC

periportal fibrosis

”end stage liver disease” (cirrhosis +/- PHT)

periportal lymph nodes

stones in the gallbladder or bile ducts

periportal fibrosis

irregular bile ducts

”end stage liver disease” (cirrhosis +/- PHT)

periportal lymph nodes

stones in the gallbladder or bile ducts

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PBC

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PSC

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PSC

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Stones in the gallbladder (PSC)

Hematoma– acute; highly reflective

– later; often inhomogeneous or hypoechogenic

– depends on age and severity of bleeding

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Malignant liver diseases

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Hepatocellular carcinoma

high prevalence in Africa and Southeast Asia (HBV and HCV)

strongly associated with cirrhosis and viral hepatitis

blood supply almost exclusively from an abnormal artery

< 2cm often hypoechogenic

large HCC (> 5 cm) often inhomogeneous with mixed echogenisity

– bleeding, necrosis and fibrosis

diffuse infiltration (DD: cirrhosis)

tumour thromb in the portal vein in about 35% using US

increased vascularity with Colour Doppler and CEUS

– ”feeding artery” and ”basket sign”

most often ”wash out” ( hypoechoic) in sinusoidal phase with CEUS

hepatic arterial

supply

abnormal arterial

supply

Arterial

supply

Portal

supply

portal supply

LRN ~ LGDN ~ HGDN ~ e-HCC ~ wdHCC ~ classical HCC

early HCC

Matsui, Clin Hep Gastro, 2005.

(based on CT-arterioportal-angiography)

The Sequence of HCC Development

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Hepatocellular carcinoma

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Hepatocellular carcinoma

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Hepatocellular carcinoma

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Hepatocellular carcinoma–”basket sign”

HCC -female 21 years of age with chronic HBV (Ethiopia 2012)

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HCC -male 53 years of age with chronic HBV and

AFP=3000 (Ethiopia 2012)

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??

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Cholangiocarcinoma

often difficult to identify by ultrasound or other imaging techniques – ill-defined and often isoechoic

dilated bile ducts proximal to tumour– ”parallel sign”

solitary tumour with a slightly inhomogeneous echogenicity

localized thickening of the bile duct wall or just a ”major stricture”

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Cholangiocarcinoma

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Cholangiocarcinoma

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Cholangiocarcinoma

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Cholangiocarcinoma

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Metastases

often multiple

hypo- and/or hyperechoic

halo

central necrosis

hypoechoic (wash-out) in parenchymal phase with CEUS

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Metastases

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Metastases

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Liver metastases – from colorectal carcinoma

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Metastases – from colorectal carcinoma

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Liver metastases

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Liver metastases

Late phase on CEUS

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Lymphoma

– most often a diffuse infiltration (abnormal echogenicity?)

– seldom localized (10%)

– biopsy

– enlarged lymph nodes?

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Diffuse malignant infiltration

myelomatosis/ plasma cell leukaemia– hepatomegaly