1. CASE PRESENTATION
By:
Dr. SHAMSHAD KHAN
TMO Radiology
HMC

2. Case A 23 year old female came with pain in right hypochondrium.
LFT’s were normal
Ultrasound abdomen was done
Which is as …….

4. Diagnosis ?

5. Polycystic liver disease

6. Polycystic liver disease
About 10 to 13 % of individuals have cysts in liver either single or multiple
Mostly are asymptomatic
LFT’s are normal in most cases
Approx 45 % occur with polycystic kidney disease

7. LIVER LESIONS on ULTRASOUND
Two main types
. Benign lesions
. Malignant lesions

8. BENIGN
Cystic which may be
Simple Cysts
Abscesses
Parasitic cysts

9. Hepato-Billiary Cystic lesions
Cont……
Hepato-Billiary Cystic lesions
Hemangioma
Caroli’s disease
Peliosis
Choledochal cyst
Veno -occlusive disease

10. Cont………
Hepatocellular
Focal Nodular Hyperplasia
Adenoma

11. MALIGNANT Hepatocellular carcinoma Fibrolamellar HCC Metastasis
Lymphoma
Hepatoblastoma

12. CYSTS Most common lesions Have three main characteristics
Anechoeic lumen
Increased through transmission
Well enhanced posterior wall
cont….

13. Simple Cyst

14. Simple Cyst with internal haemorrhage

15. May be
multiple
as in
poly cystic
liver

16. Cysts may be complex if they have
Internal echoes
Thick wall
Septations
Calcification
cont………

17. Complex cysts include
Hematomas
Abscesses
Echinococcus
Hemorrhagic tumors

18. Abscesses May be Bacterial , Fungal or amoebic
Bacterial abscesses are caused due to intestinal infection like appendicitis and diverticulitis or even caused by endocarditis.

19. Cont…
They appear as complex fluid collections with mixed echogenisity.
They may mimic solid hepatic masses but the presence of through transmission will provide clue to liquefied nature of the mass.
They may calcify with healing

20. Abscess

21. Multiple Abscesses

22. Ruptured Liver Abscess

23. Amoebic liver abscess Usually single but can be multiple
Typically located in right lobe of liver
30 to 70% are single
Appear as homogenous hypoechoeic lesions, round or oval with well defined borders

24. Amoebic liver abscess
Initial stage

25. Amoebic liver abscess
Recently
formed cyst

26. Amoebic
abscess of
duration

27. Fungal Abscesses usually occur in immunocompromised patients
Most common organism is candida
Mostly cause very small lesions (microabscesses)
Larger lesions may occur

28. cont……
Typical appearance is target lesion with central echogenic region and peripheral hypoechoeic halo.
Every lesion may have hypoechoeic focus centrally caused by necrosis and fungal elements.

29. Ultrasound features of hepatic candidiasis
“Wheel within a wheel”
peripheral hypoechoeic area
inner echogenic wheel
central hypoechoeic nidus
Bull’s eye
Hyperechoeic centre
Hypoechoeic rim
Uniformly hypoechoeic
progressive fibrosis
Echogenic
calcification representing scar formation

32. Multiple
hypoechoeic
lesions in
acute
mylogenous
leukemia

33. Hepato-Billiary Vascular Cysts
Hepato-Billiary Vasculature can also appear as Cysts as seen in
Aneurysms
Arterio-portal and Veno-portal fistulas
Caroli’s disease
Choledochal cyst

34. Caroli’s disease
Rare inherited disorder characterized by dilatation of the intrahepatic bile ducts
Two types of Caroli disease
simple or isolated case where bile ducts are widened by ectasia
2nd is complex called Caroli syndrome
associated with hypertension and congenital hepatic syndrome ia

35. Caroli’s disease
with multiple
intra hepatic
cysts

36. Caroli disease
in 9 year old
girl

37. Choledochal cyst
Congenital disease causing cystic dilatation of bile ducts
Appears in 1st year of life with jaundice and sometimes with palpable mass

38. Choledochal
cyst in 1 year
old boy

39. Choledochal cyst

40. Parasitic cysts Usually caused by Ecchinococcus granulosus
Liver is most commonly affected organ
Have an external membrane ectocyst and an internal germinal layer called endocyst.

41. cont……
In addition forms a cyst around called pericyst.
Appear on ultrasound as a simple cyst with internal daughter cysts with detatched membranes ,
with internal debris and cysts,
and with internal or peripheral calcification.

42. Hydatid cyst

43. Hydatid
Cyst with
Detached
membranes

44. BENIGN HEPATOCELLULAR LESIONS
Hemangiomas
Most common benign liver neoplasm occuring in 7 % of adults
More common in women than in men
Usually single but 10 percent are multiple

45. cont……… If small, they are asymptomatic
But if large, they have symptoms due to mass effect.

46. Small hemangiomas ( less than 3cm ) typically appear as homogenous hyper echoeic mass with sharp and smooth margins.
If large, they may be atypical as a result of thrombosis, fibrosis and necrosis.
Calcification can occur but is rare

47. Hemangioma

48. Multiple Hemangiomas

49. cont……
Some percentage of atypical hemangiomas may have hyperechoeic periphery and hypoechoeic centre.This is REVERSE TARGET SIGN characteristic of hemangiomas and is rarely seen in malignant disease.

50. Reverse Target
sign.

51. cont………
Hemangiomas are stable over time but approx. 10 % undergo decrease in echogenecity
5 % will regress partially or completely
Only 2 % enlarge on follow up scans.

52. Focal Nodular Hyperplasia
It is a benign tumor of liver composed of Kupffer cells, hepatocytes and billiary structures.
2nd most common benign liver tumor
Both FNH and Hemangioma can occur simultaneously
Develop from congenital vascular malformation

53. cont………
They are typically un encapsulated and often with central stellate scar
20 % are multiple
Supplied by internal arterial network arranged in spoke wheel pattern better displayed on doppler.
More common in women
Asymptomatic until they are large

54. FNH

55. cont…… On ultrasound they are isoechoeic May have target appearance
D/Ds include
Hemangioma
Hepatic adenoma
HCC
Fibrolamellar Carcinoma

56. FNH

57. HEPATIC ADENOMA
Benign tumors that contain normal hepatocytes but few kupffer cells and no bile ductules
Usually common in women taking birth control pills
Can also occur in males taking anabolic steroids

58. cont……
Multiple adenomas can occur in patients with type 1 Glycogen storage diseases called Hepatic Adenomatosis
On ultrasound most are homogenous and hypoechoeic
Calcification may occur in 10% of cases

59. Adenoma

60. Adenoma

61. MALIGNANT LIVER LESIONS
Metastasis
Liver and Lungs are most common sites for metastasis
Multiple in 98% cases involving both lobes
LFTs are unreliable in most cases

62. cont………
On ultrasound mostly are Target Lesions with an echogenic or iso echoeic centre and hypo echoeic halo
Target lesions are usually malignant
Other most common cause of Target Lesion is HCC

63. Metastatic lesion

64. Metastasis

65. Metastasis

66. HEPATOCELLULAR CARCINOMA
Most common primary malignancy of liver referred to as HEPATOMA
Strong association with chronic liver disease like Hepatitis B, C and Alcoholic cirrhosis
Other conditions include Hemochromatosis, Wilson disease and Type 1 Glycogen storage disease

67. cont……… May be solitary, mulifocal or diffuse and infiltrating
Typical lesion is large with scattered smaller satellite lesions

68. HCC

69. HCC

70. HCC in 8 year
old girl

71. Hypoechoeic
lesion in
solitary
HCC

72. Lymphoma Usually occurs with hepatomegaly spleenomegaly
lymphadenopathy
Mostly of Non Hodgkins variety
Mostly are single but may be multiple
Appear as hypoechoeic lesions

73. Lymphoma
Solitary
lesion

74. Lymphoma
Multiple
lesions

75. CONCLUSION
Ultrasound is best modality for differentiating solid from cystic lesions with real time imaging capabilities.
However MRI and CT scan are performed in some cases to characterize the lesions.

76. Thanks