Website : Indonesia’s World Federation of Ultrasound in

Medicine - Centre of Education

Jakarta
Liver Ultrasound for Pulmonologist

Daniel Makes

Department of Radiology, PELNI Hospital, Jakarta
World Federation for Ultrasound in Medicine & Biology ‐ Center of Education
( Indonesia’s WFUMB‐COE )
 LIVER IMAGING: US CHECKLIST
LIVER PARENCHYMA : 1. Size
2. Outline
3. Overall echogenicity: - Increased
- Decreased
- Diffuse Abnormal
4. Focal echogenicity : - Hyperechoic
- Hypoechoic
- Isoechoic
- Anechoic
5. Intra-hepatic bile duct: - Dilated ?
- Pneumobilia ?
6. Portal vein : - Dilated ?
- Thrombosed ?
- Cavernoma ?
7. Focal masses : - Single ?
- Multiple ?
Hyperechoic ? Hypoechoic ? Mixed ?
 LIVER IMAGING: US CHECKLIST FOR PULMONOLOGIST
Liver parenchyma : 1. Size
2. Outline
3. Overall echogenicity: - Increased
- Decreased
- Diffuse Abnormal
4. Focal echogenicity : - Hyperechoic
- Hypoechoic
- Isoechoic
- Anechoic
5. Intra-hepatic bile duct: - Dilated ?
- Pneumobilia ?
6. Portal vein : - Dilated ?
- Thrombosed ?
- Cavernoma ?
7. Focal masses : - Single ?
- Multiple ?
Hyperechoic ? Hypoechoic ? Anechoic ? Mixed ?
 Normal Liver Size
Niederan et al :
Midclavicular Line :
10.5 + 1.5 cm (longitudinal)
8.1 + 1.9 cm (AP)
Liver Size Assessment: Ultrasound

 Most studies use length of the liver at right mid-

clavicular line from the dome of the liver to the
inferior edge
 <13.0 cm = 93% normal
 >15.5 cm = 75% hepatomegaly
 13.0-15.5 cm = In-between
QUIZ: is there any sign of hepatomegaly ?

17 cm

Answer : YES
 Most studies use length of the liver at right mid-clavicular line
from the dome of the liver to the inferior edge
 <13.0 cm = 93% normal
 >15.5 cm = 75% hepatomegaly
 13.0-15.5 cm = In-between
Hepatomegaly
 ACUTE HEPATITIS

Normal Liver
* MILD HEPATOMEGALY
* SLIGHT DECREASED LIVER REFLECTIVITY
* PERIPORTAL BRIGHTNESS ( “ STARRY SKY “ )
* THICKENING GB WALL & CONTRACTION OF GB
* PERIPORTAL LYMPHADENOPATHY
ACUTE HEPATITIS

“ Starry Sky “
 INFECTIOUS DISEASES
* PYOGENIC ABSCESS

* FUNGAL ABSCESS

* GRANULOMATOUS DISEASE

* PARASITIC INFECTION
 PYOGENIK ABSCESS
US appearance:
-Typically appear as complex fluid collections with mixed
echogenicity.
-May mimic solid hepatic masses.
-May appear as thick-walled cystic lesions
-May calcify with healing
Liver Abscess
 PARASITIC INFECTION
- Hydatid cyst may appear as :
relatively simple cysts
cysts with multiple internal daughter
cysts
cysts with internal debris
cysts with internal or peripheral calcifi-
cation.
Amoebic abscess are indistinguishable from pyogenic abscess.
HYDATID CYST
 GRANULOMATOUS DISEASE
- Pneumocytis carinii infection
- Mycobacterium avium intracellulare

US appearance :
Multiple hyperchoic foci scattered
throughout the liver
 Normal Liver

AIDS
 Liver
Tuberculosis

 Lesions may be
hypoechoic
 Hyperechoic spots
may be present
 Calcified spots
may represent
liver tuberculoma
LIVER CIRRHOSIS
 CHRONIK LIVER DISEASE

Longitudinal Midline Subcostal

Liver Cirrhosis
Liver Cirrhosis
Liver Cirrhosis 4-D US

3-D Rotation
SIMPLE CYST
3 CLASSIC US SIGN:
• ANECHOIC LESION
• POSTERIOR
ACOUSTIC
ENHANCEMENT
• A WELL DEFINED
BACK WALL
SIMPLE CYST
 Benign Hepatic Solid
Neoplasms :
 Cavernous Hemangioma
 Hepatic Lipoma

 Focal Nodular Hyperplasia

 Hepatic Adenoma
 Angiomyolipoma
 Benign Hepatic Solid
Neoplasms :
 Cavernous Hemangioma
 Hepatic Lipoma

 Focal Nodular Hyperplasia

 Hepatic Adenoma
 Angiomyolipoma ( AML )
SMALL HEMANGIOMA

 Hyperechoic
 Homogenous
 Sharp &
smooth margin
HEMANGIOMA
Hemangioma
 Malignant Hepatic
Neoplasms

 Hepatocellular Carcinoma
 Fibrolamellar Carcinoma

 Hepatic Lymphoma

 Hemangio Sarcoma
 Metastatic Disease
 Malignant Hepatic
Neoplasms

 Hepatocellular Carcinoma
 Fibrolamellar Carcinoma
 Hepatic Lymphoma

 Hemangio Sarcoma
 Metastatic Disease
HEPATOMA
What is your DD/
Hepatoma
 LIVER METASTASES
• 50 % of patient with liver
metastases have no sign &
symptoms of liver disease
• LFT are also unreliable in
detecting liver metastases
• Therefore, IMAGING plays a
critical role in patients with
suspected liver metastases
 The majority of metastatic lesions have a
target appearance: an hyperechoic/isoechoic
center and a hypoechoic halo
LIVER METASTASIS
Liver metastases
HYPOECHOIC LIVER METASTASIS
HYPERECHOIC LIVER METASTASES
Necrotic Liver Metastases
Thank You