1. Hemangioma (Most Common Benign):
Ultrasound Features:
• Well-defined, homogeneous hyperechoic lesion.
• Usually small (<3 cm).
• Posterior acoustic enhancement present.
• No internal vascularity on Doppler.
Clinical/Lab Correlation:
• Usually asymptomatic and incidental.
• Liver function tests within normal range.
• No history of primary malignancy.
Advanced Imaging:
• CT/MRI: Peripheral nodular enhancement with centripetal fill-in (classic sign).
2. Focal Fatty Infiltration :
Ultrasound Features:
• Hyperechoic or hypoechoic area depending on fat distribution.
• No mass effect (vessels run through lesion undistorted).
• Geographic/triangular margins, often near gallbladder fossa or porta hepatis.
Clinical/Lab Correlation:
• History of obesity, diabetes, alcohol, or metabolic syndrome.
• Mildly deranged liver function tests possible.
Advanced Imaging:
• MRI in-phase vs out-of-phase shows signal drop due to fat.
3. Hepatocellular Carcinoma (HCC) – Hyperechoic Variant:
• May appear hyperechoic, especially when fatty changes or fibrous stroma are present.
• Often irregular margins, mosaic pattern, or halo sign.
• Shows internal vascularity on Doppler (arterial flow).
• Often associated with cirrhotic background liver.
Clinical/Lab Correlation:
• Elevated AFP (not always).
• History of chronic hepatitis or cirrhosis.
Advanced Imaging:
• CT/MRI: Arterial enhancement with washout in portal/venous phase (classic hallmark).
4. Metastases (Hyperechoic Type):
Ultrasound Features:
• Multiple lesions common, can be solitary.
• Variable echogenicity — hyperechoic if mucinous (colon, ovary), neuroendocrine, or melanoma.
• Irregular borders, sometimes “bull’s-eye” (target sign).
• May show variable vascularity.
Clinical/Lab Correlation:
• Known primary malignancy is the key clue.
• Systemic symptoms like weight loss, fatigue, or cachexia.
Advanced Imaging:
• CT/MRI: Multiple lesions, peripheral rim enhancement, restricted diffusion (MRI DWI).
5. Lipoma (Rare):
Ultrasound Features:
• Well-defined, strongly hyperechoic lesion.
• Usually very small (<2 cm).
• No internal vascularity.
Clinical/Lab Correlation:
• Incidental, benign, no symptoms.
Advanced Imaging:
• CT: Fat attenuation (negative HU).
• MRI: Signal drop on fat-suppressed sequences confirms diagnosis.
| Lesion | Ultrasound (US) Features | Clinical/Lab Clues | CT/MRI Correlation |
|---|---|---|---|
| Hemangioma | Small, well-defined, homogeneous hyperechoic; posterior enhancement; no Doppler flow | Incidental, normal LFTs | Peripheral nodular enhancement, centripetal fill-in |
| Focal Fatty Change | Hyperechoic area, no mass effect, vessels pass through | Obesity, diabetes, metabolic syndrome | Signal drop on out-of-phase MRI |
| HCC (Hyperechoic) | Hyperechoic with irregular margins, halo sign, Doppler vascularity | Cirrhosis, ↑AFP, hepatitis | Arterial enhancement + venous washout |
| Metastases | Multiple, variable, may be hyperechoic (mucinous, neuroendocrine) | Known primary cancer | Multiple lesions, rim enhancement, DWI restriction |
| Lipoma | Small, very hyperechoic, well-defined, avascular | Incidental finding | Fat attenuation on CT, fat suppression on MRI |
"Bright liver lesions often look alike — the skill lies in knowing their subtle differences."
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