Diffuse Changes

Table 41 ■ Diffuse changes in hepatic echogenicity or contours Subtle Pronounced

Alimentary or diabetic fatty liver (p. 234)

Acute hepatitis (p. 235) Chronic hepatitis (p. 235) Fibrosis (p. 235) Congestive cirrhosis (p. 236)

Incipient hepatic cirrhosis (p. 236) Diffuse metastasis, systemic hematologic disease (p. 239)

Sarcoidosis (p. 237)

Micronodular abscesses, metastases (p. 237)

Toxic fatty liver, chronic toxic liver disease (p. 237)

Severe chronic hepatitis, hepatic cirrhosis (p. 238)

Diffuse metastasis, metastatic liver during chemotherapy

n Alimentary or diabetic fatty liver (Fig. 322):

• Slight coarsening of the parenchymal echo pattern and increased echogenicity in relation to the kidney

• Moderate (14-16 cm) to severe (17-20 cm) hepatic enlargement in longitudinal section on the MCL

• Minimal acoustic shadowing on the far side of the liver

• Rounded hepatic contours

Micronodular Contour
Fig. 322a, b Fatty liver (L, LE). a Slight coarsening of the parenchymal echo pattern, increased echogenicity, distal acoustic shadowing, and organ enlargement. b Longitudinal scan shows increased hepatic echogenicity (relative to the kidney) and a rounded inferior border (arrows). K = kidney

n Acute hepatitis:

• Markedly good sound transmission or slightly increased echogenicity

• Inflammatory hilar lymphadenopathy

• Splenomegaly

• Empty gallbladder with a thickened wall n Chronic viral hepatitis (Fig. 323): variable echogenicity and contour changes, ranging from a normal-appearing liver (mild or "persistent" hepatitis with low activity) to changes like those seen in an early form of hepatic cirrhosis (severe or "aggressive" hepatitis with high activity).

• Sonographic signs:

- Slight coarsening of the parenchymal echo pattern. Acoustic shadowing is seen in chronic toxic liver disease.

- Slight lobulation of the contours

- Incipient dilatation of the portal vein

- Frequent splenomegaly

- Caliber irregularities in the hepatic veins

Coarse Parenchymal Liver
Fig. 323a, b Chronic hepatitis C, mild form. a Very slight coarsening of the parenchymal echo pattern and increased sonodensity with faint acoustic shadowing. Right subcostal scan. b CDS: inflammatory hilar lymphadenopathy (LN). Right intercostal scan through the porta hepatis. VC = vena cava

• Slightly coarsened or mottled echo texture (if secondary to inactive chronic hepatitis or cirrhosis, resembles the appearance of chronic hepatitis or cirrhosis but with essentially normal liver values).

Ascites Abdominal Vein Patterns
Fig. 324a, b Hepatic fibrosis. a Congenital fibrosis in a 23-year-old woman with portal hypertension following the placement of a portosystemic shunt. A = ascites. b Inactive chronic sclerosing cholangitis with marked fibrosis: coarse high-level echoes, wavy course of the hepatic vein (arrows) 235

• Coarse, heterogeneous echo pattern

• Possible distal acoustic shadowing as in a fatty liver n Congestive cirrhosis (Fig. 325):

• Hepatic echogenicity is normal or slightly increased (can be clearly evaluated owing to increased vascularity); rounded contours

• Hepatomegaly

• Hepatic veins and vena cava are dilated, do not show caliber variations with respiration

• Enlarged caudate lobe

• Possible associated findings: ascites, portal vein dilatation, splenomegaly

Fig. 325 Congestive cirrhosis. The liver still has a normal parenchymal echo pattern, but note the curved, bulging inferior border and the tiny breaks in the capsule (arrows). A = ascites

n Hepatic cirrhosis (Fig. 326): In early and intermediate stages (Child A and B), there may be only slight coarsening of the parenchymal echo pattern with very little disruption or lobulation of the liver contours, resulting in an absence of characteristic changes (Table 42).

Table 42 ■ Sonographic features of hepatic cirrhosis

Direct signs

Coarsening of the parenchymal echo pattern (stippled to mottled pattern)

Enlargement and hypoechoic transformation of the caudate lobe Bulging contours

Vascular irregularities, bowing, abrupt caliber changes

Recanalized umbilical vein

Breaks in the capsule ("brush" or "shingled roof" appearance)

Luminal expansion of the hepatic artery (see Fig. 368, p. 259)

Indirect signs

Intrahepatic portal vein dilatation i 11 mm, flow changes (see p. 259)

Portal vein dilatation in the hepatoduodenal ligament i 13-15 mm

Splenomegaly

Ascites

Portosystemic collaterals

Sonographic Images The Liver

Fig. 326a, b Hepatic cirrhosis, Child stage A. a Autoimmune cirrhosis: minimal changes in the echo pattern, slightly wavy contour, increased portal vein diameter (14.2 mm, cursors). b Hepatic cirrhosis in GAVE syndrome: bulky, slightly wavy hepatic border with hepatomegaly. The patient presented clinically with recurrent gastric bleeding, a Quick PT of 60%, and a history of alcohol abuse. L = liver, K = kidney

Fig. 326a, b Hepatic cirrhosis, Child stage A. a Autoimmune cirrhosis: minimal changes in the echo pattern, slightly wavy contour, increased portal vein diameter (14.2 mm, cursors). b Hepatic cirrhosis in GAVE syndrome: bulky, slightly wavy hepatic border with hepatomegaly. The patient presented clinically with recurrent gastric bleeding, a Quick PT of 60%, and a history of alcohol abuse. L = liver, K = kidney n Sarcoidosis (Fig. 327):

• Pronounced coarsening of the parenchymal echo pattern

• Hypoechoic micronodular infiltrates

Hypoechoic Kidney Texture

Fig. 327 Sarcoidosis of the liver: coarse parenchymal echo pattern, nonvisuali-zation of the vessels, and multiple small hypoechoic foci (arrows)

n Micronodular abscesses or metastases (Fig. 328):

• Coarse, grainy hypoechoic texture

• Vessels faint or not visualized (compression by portal vessels, hepatic veins)

n Micronodular abscesses or metastases (Fig. 328):

• Coarse, grainy hypoechoic texture

• Vessels faint or not visualized (compression by portal vessels, hepatic veins)

Grainy Liver Pictures Person
Fig. 328a, b Micronodular infiltrates in the liver (L). a Microabscesses in urosepsis: grainy hypoechoic texture (same appearance as mycotic abscesses). b Micronod-ular hypoechoic metastases from a neuroendocrine tumor. K = kidney 237

n Toxic fatty liver, chronic toxic (drug- or alcohol-induced) liver disease (Fig. 329): With increasing severity and fibrous transformation, structural changes tend to occur:

• Generally increased echogenicity with individual coarse echoes

• Acoustic shadowing, even with minimal depth of involvement

• Caliber irregularities and nonvisualization of hepatic veins and small portal venous branches

• Incipient lobulation and granularity of hepatic contours

• Progressive increase in portal vein diameter

Fig. 329 Severe chronic, drug-induced toxic liver disease with fibrosis: dense, granular hyperechoic texture with no detectable vessels and marked acoustic shadowing (same appearance as chronic toxic alcoholic liver disease with structural transformation)

n Severe chronic hepatitis with structural change or cirrhosis (Figs. 330 and 331):

n Note: The echo pattern and contours of the liver depend on the extent of the changes, the degree of fibrous transformation that has occurred, and the etiology of the cirrhosis. The appearance of the portal vessels, the presence of ascites, and the size of the spleen depend on the severity of portal hypertension and on inflammatory activity.

• Direct and indirect sonographic signs: see Table 42, p. 236

• Sonographic signs indicating the etiology of cirrhosis: see Table 43.

Fig. 330a, b Advanced chronic viral hepatitis, hepatic cirrhosis. a Severe chronic hepatitis B: patchy structural transformation with poor delineation of the hepatic veins. b Child stage B hepatic cirrhosis in hepatitis C: coarse, echogenic areas of fibrosis with massive enlargement of the caudate lobe (CL). CL:RL (right liver) = 74:43 mm = 1.7 (cursors; normal ratio J 0.55)

Hepatic Congestion Ultrasound

liver surface. "Brush" or "file" appearance due to fine surface nodularity (after Rettenmaier)

Table 43 • Sonographic signs indicating the etiology of cirrhosis

Hepatic cirrhosis

Alcoholic cirrhosis

Congestive cirrhosis

Coarsening of the parenchymal echo pattern Bulging contours

Hypoechoic regenerative nodules (caution: primary hepatic carcinoma!) Altered vascular architecture on CDS (curved veins with irregular calibers, "pruned" portal veins, dilated hepatic artery)

Organ enlargement

Fine, diffuse coarsening of the echo pattern

Increased echogenicity

Enlarged liver

Mostly smooth but often bulging contours, good through transmission due to hepatic venous congestion (no luminal change with respirations) Vena cava congestion

Distal acoustic shadowing

Small contour bulges with breaks in the capsule (brush or file appearance) Altered vascular architecture on CDS

No bowing of vessels or caliber irregularities by CDS

Ascites n Diffuse metastasis or hepatic metastases during chemotherapy, systemic hematologic diseases (Figs. 332 and 333):

• Increased parenchymal echogenicity

• Distal acoustic shadowing (as in a fatty liver)

• Slightly irregular or hazy echo pattern

• Bulging contours

• CDS: vascular displacement, infiltration, spot-like vascularity

• Possible associated finding: microcalcification

Sonographic Images Ivc Carcinomas
Fig. 332a, b Metastatic liver in a patient with colorectal carcinoma. a B-mode: heterogeneous parenchymal echo pattern with no evidence of discrete metastases. b CDS: A normal vascular architecture is no longer detectable. The irregular spots of vascularity indicate the extent of liver destruction

n Role of sonography: Ultrasound cannot replace histology, but it can do the following:

• Detect previously unknown findings with high confidence

• Narrow the differential diagnosis based on sonographic features

• Classify a clinically presumed liver disease as diffuse or focal, often permitting a specific diagnosis to be made

• Eliminate or lessen the need for invasive endoscopic procedures (laparoscopy)

• Provide an accuracy rate of almost 80% in the diagnosis of hepatic cirrhosis n Indications for histology:

• Diagnosis of hepatitis and evaluation of its inflammatory activity

• Differentiation of hepatitic cirrhosis from siderocirrhosis; differentiation of alcoholic fatty liver from diabetic or toxic drug-induced fatty liver and from a storage disease n Further tests: These depend upon sonographic and clinical findings:

• Findings characteristic of a fatty liver:

- Additional tests are unnecessary unless there is a discrepancy between clinical and ultrasound findings. In this case an ultrasound-guided percutaneous liver biopsy should be done to differentiate other conditions with a similar

Gaucher Disease Ultrasound

Fig. 333 Chronic myeloid leukemia with diffuse cellular infiltration: slight coarsening of the parenchymal echo pattern with distal acoustic shadowing echo pattern: chronic hepatitis C, Gaucher disease, toxic liver disease, NASH, jj diffuse malignant infiltrates .-J

- Only exceptional cases require confirmation by blind liver biopsy (after locating the puncture site sonographically) or by laparoscopy

• Suspected metastasis or unexplained ascites:

- Laparoscopy and histologic evaluation

- Sonography: use CDS, contrast-enhanced sonography, and THI

- Other imaging studies such as CT angiography and MRI

• Symptoms of cholestasis (e.g., sclerosing cholangitis): Evaluate by ERC.

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  • marcel
    What is hepatomegaly with high sonodensity?
    3 years ago

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