Diagnostic Ultrasound - Abdomen and Pelvis

Hepatomegaly
– Firm consistency (due to inflammation) on dynamic
scanning during cardiac cycle
– Irregular borders of hepatic veins due to hepatic
inflammation
– Intermittent loss of visualization of hepatic veins
• Fatty Cirrhosis
○ Enlarged left and caudate lobes and atrophic right lobe
○ Hyperechoic but heterogeneous liver echo pattern
○ Irregular hepatic veins
○ Portal venous collaterals
○ Stiff consistency
○ Ancillary signs of portal hypertension
– Ascites, varices, hepatofugal flow, splenomegaly
• Venoocclusive Disease
○ Hepatosplenomegaly and ascites
○ Periportal and gallbladder wall edema
○ Narrowing and monophasic waveform of hepatic veins
due to hepatic edema
○ Slow or reversed flow in portal vein
○ Prominent hepatic arteries and elevated arterial peak
systolic velocity
○ Abnormal hepatic arterial resistive index
– < 0.55 or > 0.75 (variably seen)
• Diffuse Neoplastic Infiltration
○ Infiltrative Hepatocellular Carcinoma
– Ill-defined area of markedly heterogeneous
echotexture
□ Often indistinguishable from underlying cirrhosis
– Color Doppler: Malignant portal vein thrombosis
□ Absence of normal blood flow and presence of
hypoechoic thrombus extending into portal vein
□ Presence of arterialized flow in portal vein
thrombus: High PPV but moderate sensitivity
○ Lymphoma
– Diffuse/infiltrative form presents as innumerable
subcentimeter hypoechoic foci
– Miliary pattern
– Periportal location
– Infiltrative pattern may be indistinguishable from
normal liver
– Also look for lymphadenopathy, splenomegaly or
splenic lesions, bowel wall thickening, ascites
○ Metastases
– Discrete nodules and masses or infiltrative pattern
– Lung or breast cancer: Common primary showing
infiltrative pattern hepatic metastases
– Infiltrative pattern shows heterogeneous echotexture
and simulates cirrhosis
Helpful Clues for Less Common Diagnoses
• Sarcoidosis
○ Hepatosplenic involvement
– Most common finding: Nonspecific
hepatosplenomegaly
– Diffuse parenchymal heterogeneous echotexture
– Numerous small nodular pattern
– Advanced disease may cause or simulate cirrhosis
○ Can affect almost every organ
– Most common site: Lung
○ Upper abdominal lymphadenopathy often present
• Glycogen Storage Disease
○ Hepatomegaly and multiple hepatic adenomas in
chronically ill young patients
○ Liver may appear diffusely echogenic
– Indistinguishable from fatty liver
○ Requires biopsy for diagnosis
SELECTED REFERENCES
1. Faraoun SA et al: Budd-Chiari syndrome: a prospective analysis of hepatic
vein obstruction on ultrasonography, multidetector-row computed
tomography and MR imaging. Abdom Imaging. ePub, 2015
2. Reynolds AR et al: Infiltrative hepatocellular carcinoma: what radiologists
need to know. Radiographics. 35(2):371-86, 2015
3. Heller MT et al: The role of ultrasonography in the evaluation of diffuse liver
disease. Radiol Clin North Am. 52(6):1163-75, 2014
4. Kratzer W et al: Factors affecting liver size: a sonographic survey of 2080
subjects. J Ultrasound Med. 22(11):1155-61, 2003
Differential Diagnoses: Liver
Congested Liver
Budd-Chiari Syndrome
(Left) Oblique ultrasound of
the liver at the level of the
hepatic venous confluence
shows an enlarged liver with
marked dilatation of hepatic
veins ſt and IVC indicating
hepatic congestion in a patient
with right heart failure.
(Right) Transverse abdominal
ultrasound in a patient with
Budd-Chiari syndrome shows
heterogeneous hepatic
parenchymal echogenicity ſt
and hypertrophied caudate
lobe . The caudate is often
hypertrophied in the setting of
Budd-Chiari due to its separate
venous drainage into the IVC.
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