Diagnostic Ultrasound - Abdomen and Pelvis

Irregular Hepatic Surface
Differential Diagnoses: Liver
DIFFERENTIAL DIAGNOSIS
Common
• Cirrhosis
• Subcapsular Hepatic Neoplasm
• Hepatic Metastasis
• Infiltrative Hepatocellular Carcinoma
• Postsurgical Hepatic Resection
Less Common
• Hepatic Rupture
• Schistosomiasis
ESSENTIAL INFORMATION
Helpful Clues for Common Diagnoses
• Cirrhosis
○ Nodular surface contour
– Micronodular (< 1 cm diameter): Due to alcoholism
– Macronodular: Due to viral hepatitis
○ Hypertrophy of caudate lobe and lateral segment of left
lobe
○ Atrophy of right lobe and medial segment of left lobe
○ Widening of fissures
○ Coarse/nodular/heterogeneous parenchymal
echotexture
• Subcapsular Hepatic Neoplasm
○ Primary or secondary subcapsular neoplasm may distort
surface contour when large or numerous
○ Lesions cause architectural distortion of liver
parenchyma
• Hepatic Metastasis
○ Commonly due to gastric, ovarian, breast, or pancreatic
primary
○ Treated metastases (e.g., from breast) may shrink and
fibrose, simulating nodular contour of cirrhotic liver
• Infiltrative Hepatocellular Carcinoma
○ Margins of tumor often indistinct
○ May see refractive shadows emanating from hepatic
parenchyma
○ Portal triads may be effaced or invaded
○ Often associated with tumor thrombus in the portal vein
or hepatic vein (less common)
• Postsurgical Hepatic Resection
○ Combination of surgical defect and surrounding scarring
causes irregularity of contour
○ Surgical material ± fat in surgical defect causes further
heterogeneity of surgical site
Helpful Clues for Less Common Diagnoses
• Hepatic Rupture
○ Echogenic blood clot on surface of liver
○ May see breach of hepatic capsule or irregularity of
capsular surface if underlying lesion is hepatocellular
carcinoma
○ Hemoperitoneum may be present
– More echogenic than ascites
○ Underlying cause
– Large or exophytic hepatocellular carcinoma or other
tumor
– Spontaneous hepatic rupture associated with HELLP
(hemolysis, elevated liver enzymes, and low platelets)
syndrome
□ Thought to be secondary to endothelial
dysfunction and thrombotic microangiopathy
• Schistosomiasis
○ Irregular/notched, liver surface
○ Echogenic periportal fibrotic bands (most severe at porta
hepatis)
○ Mosaic pattern: Network of echogenic septa outlining
polygonal areas of normal-appearing liver
– Represents complete septal fibrosis (inflammation
and fibrosis as reaction to embolized eggs)
SELECTED REFERENCES
1. Goel A et al: Pregnancy-related liver disorders. J Clin Exp Hepatol. 4(2):151-
62, 2014
2. Irshad A et al: Current role of ultrasound in chronic liver disease: surveillance,
diagnosis and management of hepatic neoplasms. Curr Probl Diagn Radiol.
41(2):43-51, 2012
3. Tchelepi H et al: Sonography of diffuse liver disease. J Ultrasound Med.
21(9):1023-32; quiz 1033-4, 2002
(Left) Transverse color
Doppler ultrasound in a
patient with cirrhosis shows a
nodular and irregular liver
surface st. A large amount of
simple ascites is consistent
with portal hypertension
related to underlying liver
disease. (Right) Longitudinal
high-resolution US in a patient
with liver cirrhosis shows a
nodular and irregular liver
capsule st and heterogeneous
echotexture of the underlying
liver parenchyma. Imaging at
higher frequencies focused at
the level of liver capsule may
help identify early or subtle
cirrhosis.
Cirrhosis
Cirrhosis
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