Diagnostic Ultrasound - Abdomen and Pelvis

Hypoechoic Liver Mass
– Adjacent hepatic parenchyma may demonstrate
reactive hypervascularity
Helpful Clues for Less Common Diagnoses
• Hepatic Lymphoma
○ Hypoechoic mass with irregular margins
○ Marked hypoechogenicity
– Probably due to high cellular density and lack of
background stroma
○ Large/conglomerate masses may appear to contain
septa and mimic abscesses
– May have a "pseudocystic" appearance
○ Other sites of involvement commonly seen
– Lymphadenopathy, splenomegaly ± focal splenic
lesions provide clues to diagnosis
• Hepatic Adenoma
○ Only slightly hypoechoic compared to normal liver
parenchyma
– May be isoechoic
○ May have hypoechoic rim
○ Complications: Hemorrhage, central necrosis, and
rupture may be present
○ Color Doppler shows distinct venous vascularity at
borders
• Focal Nodular Hyperplasia
○ Usually homogeneous and isoechoic to liver
– Occasionally hypoechoic or hyperechoic
○ Central hypoechoic stellate scar with radiating fibrous
septa
○ Mass effect
– Displacement of normal hepatic vessels and ducts
○ Color Doppler: Hypervascularity
– "Spoke-wheel" pattern
□ Large central feeding artery with multiple small
vessels radiating peripherally
– Large draining veins at tumor margin
– Hemorrhage is rare
• Atypical Hemangioma
○ < 10% of hemangiomas are hypoechoic to liver
parenchyma
– Usually with hyperechoic rim
– "Typical atypical" appearance
○ May appear hypoechoic in fatty liver
– Due to background hyperechoic liver
○ Hypoechoic areas within large lesions
– May represent necrosis, hemorrhage, scar, or vessels
○ Smooth, well-defined borders
○ May see posterior acoustic enhancement
○ No visible color Doppler flow
– Flow too slow to be detected
– May be detected with power Doppler
• Hepatic Hematoma
○ Echogenicity evolves over time
– Initially: Echogenic
– After 4-5 days: Hypoechoic
– After 1-4 weeks: Internal echoes and septations
• Abnormal Bile Ducts
○ Dilated duct with sludge or tumor
○ Interrogate in perpendicular plane to show its tubular
nature
• Abnormal Vessels
○ Dilated portal or hepatic vein with hypoechoic thrombus
○ Interrogate in perpendicular plane to show its tubular
nature
SELECTED REFERENCES
1. Corvino A et al: Contrast-Enhanced Ultrasound in the Characterization of
Complex Cystic Focal Liver Lesions. Ultrasound Med Biol. ePub, 2015
2. Kunze G et al: Contrast-enhanced ultrasound in different stages of pyogenic
liver abscess. Ultrasound Med Biol. 41(4):952-9, 2015
3. Klotz T et al: Hepatic haemangioma: common and uncommon imaging
features. Diagn Interv Imaging. 94(9):849-59, 2013
4. Bhatnagar G et al: The varied sonographic appearances of focal fatty liver
disease: review and diagnostic algorithm. Clin Radiol. 67(4):372-9, 2012
5. Bartolotta TV et al: Focal liver lesions: contrast-enhanced ultrasound. Abdom
Imaging. 34(2):193-209, 2009
6. Wang ZL et al: Undetermined focal liver lesions on gray-scale ultrasound in
patients with fatty liver: characterization with contrast-enhanced ultrasound.
J Gastroenterol Hepatol. 23(10):1511-9, 2008
7. D'Onofrio M et al: Hypoechoic focal liver lesions: characterization with
contrast enhanced ultrasonography. J Clin Ultrasound. 33(4):164-72, 2005
Differential Diagnoses: Liver
Complicated Benign Hepatic Cyst
Hepatic Metastases
(Left) Longitudinal oblique US
of the liver shows a
complicated liver cyst ſt with
internal layering debris st
from hemorrhage. Depending
on age and amount internal
hemorrhage, degree of
echogenicity in a complicated
cyst may vary. (Right)
Grayscale abdominal US in a
patient with breast cancer
shows multiple well-defined
hypoechoic metastatic lesions
ſt in the liver. Large amount
of ascites is seen .
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