Purpose and Clinical Relevance
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Indications for Liver Ultrasound
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Normal Liver Size Chart by Age/Gender
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Lobes US Anatomy
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Segments US Anatomy
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Diaphragm Thickness Assessment
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Hepatic Artery Doppler Anatomy
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Portal Vein Ultrasound Anatomy
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Hepatic Veins Ultrasound Anatomy
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Biliary System Anatomy
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Polycystic Liver Disease (PCLD) Type I
Liver showing posterior acoustic enhancement without internal septations, solid components, or mural nodules. No distortion of hepatic architecture or compression of vascular structures noted. Features are consistent with Polycystic Liver Disease – Type I.
Polycystic Liver Disease (PCLD) Type II
Multiple cysts with distortion of hepatic architecture — PCLD Type II.
Polycystic Liver Disease (PCLD) Type III
Extensive cystic involvement with gross distortion and hepatomegaly — PCLD Type III.
Congenital Hepatic Fibrosis (CHF)
Hepatomegaly with increased periportal echogenicity and irregular fibrotic bands — suggestive of CHF.
Caroli Disease
Multiple cystic/dilated intrahepatic bile ducts communicating with the biliary tree (central dot sign) — Caroli disease.
Simple Caroli Disease
Multiple cystic, tubular intrahepatic structures communicating with bile ducts (central dot sign) — simple Caroli disease.
Caroli Syndrome
Intrahepatic bile duct dilatations with periportal fibrosis/portal hypertension — Caroli syndrome.
Aberrant Hepatic Veins / Accessory Fissures
Anomalous course of hepatic veins with variant drainage.
Hepatic Simple cyst
A solitary, well-circumscribed, thin-walled anechoic lesion with posterior acoustic enhancement, measuring 67 x 46 mm in the righ hepatic lobe, without septations, solid component, or vascularity. No intrahepatic biliary dilatation or additional focal hepatic lesion seen. Findings consistent with a Hepatic Simple Cyst.
Conclusion: Benign hepatic simple cyst. No features to suggest parasitic, neoplastic, or complicated cyst.
Recommendation: No active intervention required. Symptomatic management if bloating persists. Follow-up ultrasound only if lesion enlarges or symptoms develop.
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Beaver Tail Liver
Left hepatic lobe elongated, wrapping along the spleen — normal anatomical variant.
Hydatid Cyst (Cystic Echinococcosis) Stage – CE1
Liver shows a well-defined anechoic cyst with double wall sign, consistent with hydatid cyst (CE1).
Conclusion: 00
Recommendation: 00
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Daughter cysts (Rosette Appearance) (CE2)
Multiloculated hepatic cyst with multiple peripheral daughter cysts arranged in a rosette pattern, suggestive of hydatid cyst (CE2 stage).
Conclusion: 00
Recommendation: 00
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Multivesicular / Septated Cyst (Cartwheel sign or Honeycomb appearance) (CE2)
Cystic lesion with multiple internal septations and daughter cysts arranged in a cartwheel / honeycomb pattern, suggestive of multivesicular hydatid cyst (CE2).
Cyst with Detached Membrane (Water-lily sign) (CE3a)
Well-defined cystic lesion in the liver showing internal floating membranes (‘water-lily sign’), suggestive of hydatid cyst with detached endocyst.
Hydatid cyst (Serpent Sign) (CE3a)
Cystic lesion in the liver with floating wavy undulating membranes (‘serpent sign’), suggestive of hydatid cyst with detached endocyst.
Cyst with Solid Matrix & Daughter Cysts (Ball of wool sign) (CE3b)
Cystic lesion with heterogeneous solid matrix containing multiple daughter cysts, showing ‘ball of wool’ appearance, suggestive of hydatid cyst (transitional stage, CE3b).
Cyst with Snowstorm / Hydatid Sand (CE4)
Liver shows a well-defined cystic lesion with internal echogenic mobile echoes producing a ‘snowstorm / hydatid sand’ appearance, suggestive of Hydatid Cyst (CE4).
Hydatid cyst (Eggshell Calcification) (CE5)
Well-defined hepatic cyst with thick, curvilinear peripheral wall calcification (‘eggshell calcification’), suggestive of inactive hydatid cyst / calcified cyst (CE5 stage).
Pyogenic Liver Abscess
Complex cystic lesion with internal echoes/septations and peripheral vascularity — pyogenic abscess.
Amoebic Liver Abscess
Solitary hypoechoic lesion with low-level echoes, absent internal vascularity — amoebic abscess.
Candidiasis Microabscess Stage
Multiple tiny hypoechoic target-like lesions — hepatic candidiasis.
Candidiasis Chronic Stage
Multiple hypoechoic to hyperechoic nodules with calcifications — chronic hepatic candidiasis.
Candidiasis Diffuse Involvement
Innumerable small target-like hypoechoic lesions in a miliary pattern — disseminated candidiasis.
Hepatic Tuberculosis Micronodular (Miliary) Form
Hepatomegaly with multiple tiny (<2 mm) hypoechoic nodules; few isoechoic/hyperechoic — miliary hepatic TB.
Hepatic Tuberculosis Macronodular (Nodular/Tuberculoma) Form
Focal macronodular lesions (>2 cm), variable echogenicity; some liquefaction — tubercular involvement.
Hepatic Tuberculosis (Miliary) Form
Hepatomegaly with multiple tiny (<2 mm) hypoechoic nodules; some with central caseation and necrosis — miliary hepatic TB.
Acute Viral Hepatitis
Liver is enlarged with hypoechoic parenchyma and accentuated periportal echogenicity (‘starry sky’ sign). Features suggestive of acute viral hepatitis.
Chronic Viral Hepatitis
Liver shows mild hepatomegaly with coarse parenchymal echotexture. Portal tracts appear echogenic. Features consistent with chronic viral hepatitis.
Perihepatitis / Fitz-Hugh-Curtis Syndrome
Liver parenchyma appears normal. Hepatic capsule shows thickening with subtle perihepatic fluid/adhesions. Features are suggestive of perihepatitis (Fitz-Hugh-Curtis Syndrome) in the setting of pelvic inflammatory disease.
Diffuse hepatic steatosis Grade-i (Fatty liver)
Increased echogenicity with posterior attenuation; blunted portal margins.
Diffuse hepatic steatosis Grade-i (Fatty liver)
Increased echogenicity with posterior attenuation; blunted portal margins.
Diffuse hepatic steatosis Grade-ii (Fatty liver)
Increased echogenicity with attenuation and blurring of portal/hepatic vein margins.
Diffuse hepatic steatosis Grade-iii (Fatty liver)
Marked echogenicity with poor diaphragm/vessel visualization due to attenuation.
Non-alcoholic fatty liver disease
Diffuse increased echogenicity with attenuation and blurring of vessel margins (NAFLD).
Focal hepatic fat (Focal hepatic steatosis)
Focal increased echogenicity without mass effect; vessels traverse normally.
Nodular focal fat sparing
Well-defined hypoechoic area without mass effect; normal vessels through it.
Multifocal fatty liver deposition/Multifocal nodular hepatic steatosis
Multiple hyperechoic nodules without mass effect; preserved vascular architecture.
Autoimmune Hepatitis
Liver is enlarged with coarse echotexture and periportal hyperechogenicity. Findings may be suggestive of autoimmune hepatitis; correlation with serology advised.
Glycogen Storage Disease
Marked hepatomegaly with increased echogenicity; homogeneous texture — GSD.
Type I – Von Gierke Disease
Hepatomegaly with diffuse echogenicity — GSD Type I.
GSD Type II – Pompe Disease
Echogenic liver ± cardiomegaly — GSD Type II.
GSD Type III – Cori / Forbes Disease
Enlarged echogenic coarse liver — GSD Type III.
GSD Type IV – Andersen Disease
Coarse, heterogeneous echotexture with fibrosis/cirrhosis features — GSD IV.
GSD Type V – McArdle Disease
Normal liver sonographically; muscle changes may be seen — GSD V.
GSD Type VI – Hers Disease
Mild–moderate hepatomegaly with homogeneous increased echogenicity — GSD VI.
GSD Type VII – Tarui Disease
No significant hepatic abnormality; muscle findings may be present — GSD VII.
GSD Type IX – Phosphorylase Kinase Deficiency
Hepatomegaly with diffusely echogenic parenchyma — GSD IX.
GSD Type 0 (Hepatic Glycogen Synthase Deficiency)
Normal sonographic liver; correlate clinically — GSD 0.
Amyloidosis
Hepatomegaly with diffusely heterogeneous increased echogenicity.
Hemochromatosis
Hepatomegaly with diffusely increased echogenicity; coarse texture.
Wilson Disease
Coarse heterogeneous liver, increased echogenicity, irregular margins — chronic disease.
Stag head sign (Dilated IVC and hepatic veins)
The short axis view of the IVC and the hepatic veins show dilation: measures of 29 mm IVC & 15 mm main hepatic vein dilation. Features are compatible with Stag head sign. Oblique subxiphoid window showing pleural anechoic collection compatible with right pleural effusion.
Portal Vein Thrombosis
Echogenic thrombus with cavernoma and periportal collaterals — chronic PVT.
3-Budd-Chiari Syndrome
HV/IVC thrombus with reduced/absent flow; hepatomegaly; heterogeneous parenchyma.
Congestive Hepatopathy
Hepatomegaly with coarse texture; dilated hepatic/portal veins; loss of venous phasicity.
Portal Hypertension
Dilated PV with reduced hepatopetal flow; splenomegaly; collaterals.
Focal Arteriovenous Malformation
High-velocity, low-resistance arterial flow with early venous filling — AVM.
Hepatic Arteriovenous Malformation
Multiple anechoic channels with turbulent color flow; arterialized venous waveforms.
Echogenic Hemangioma
Well-defined, homogeneously hyperechoic lesion with enhancement; no internal Doppler flow.
Hypoechoic Hemangioma
Well-defined hypoechoic lesion with enhancement; minimal/no internal Doppler flow.
Heterogeneous Hemangioma
Predominantly hyperechoic lesion with enhancement; peripheral Doppler flow — atypical; consider CE imaging.
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Massive HCC (single lesion)
Finding (Ultrasound report line_)
Liver shows a large heterogeneous hypoechoic mass lesion in the right lobe (segments V–VIII) measuring 114x92 mm, with lobulated margins, central necrosis and prominent intralesional arterial flow on colour Doppler. Right portal vein demonstrates an intraluminal echogenic filling defect with internal vascularity, consistent with tumour thrombus. Background liver is coursed in appearance. No significant ascites.
Conclusion: Large heterogeneous hepatic mass with arterialised vascularity and portal vein tumour thrombus — findings are most consistent with a Single Massive Hepatocellular Carcinoma (HCC).
Recommendation: Triphasic contrast-enhanced CT or MRI liver for staging and treatment planning. Correlation with serum AFP. Multidisciplinary team (MDT) review (hepatology / oncology / surgery) advised for management decision — surgical resection vs locoregional therapy (TACE/ablation) vs systemic therapy. Assess transplant eligibility if criteria are met.
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Massive HCC (multiple lesion)
Finding (Ultrasound report line_)
Liver appears cirrhotic with coarse, nodular echotexture. Multiple large heterogeneous masses are noted in both hepatic lobes, the dominant lesion in the right lobe (segments V–VIII) measures 85 x 65 mm, and another large lesion in the left lobe (segment II–III) measures 35 × 32 mm. Additional satellite nodules are seen in both lobes. Lesions are predominantly hypoechoic with central necrotic areas and irregular lobulated margins. Colour Doppler shows prominent chaotic arterial flow within the dominant masses. Right portal vein shows intraluminal echogenic filling defect with internal vascularity, consistent with tumour thrombus.
Conclusion: Multifocal massive hepatocellular carcinoma involving both lobes of the liver, with vascular invasion (portal vein tumour thrombus) in a cirrhotic background.
Recommendation: Triphasic contrast-enhanced CT or MRI liver for staging and treatment planning. Correlation with serum AFP. Multidisciplinary team (MDT) review advised to assess options — liver transplantation (if within criteria), locoregional therapy (TACE/TAE), systemic therapy, or palliative care depending on tumour burden, vascular invasion, and hepatic reserve.
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HCC PV invasion suspected
Portal vein tumor thrombus with internal arterial flow HCC.
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Hepatic Adenoma
Well-circumscribed lesion; variable echogenicity; minimal vascularity — adenoma.
Focal Nodular Hyperplasia (FNH)
Well-circumscribed homogeneous lesion; central Doppler vascularity — FNH likely; consider CE imaging.
Echogenic Metastases
Multiple confluent hyperechoic nodules — metastases.
Hypoechoic Metastases
Numerous hypoechoic nodules — metastases.
Chronic Active Hepatitis → Cirrhosis Progression
Acute hematoma
Poorly defined hyperechoic/heterogeneous area — acute hematoma.
Organizing hematoma
Well-defined hypoechoic to complex cystic lesion with septations/debris — subacute hematoma.
Chronic hematoma
Encapsulated hypo/anechoic lesion with residual echoes — chronic resolving hematoma.
Liver Laceration
Irregular linear hypoechoic defect with perihepatic fluid — laceration.
Subcapsular Hemorrhage
Hyperechoic subcapsular collection indenting surface — acute subcapsular hematoma.
Hepatomegaly
Finding (Ultrasound report line_)
Liver is enlarged in size with rounded inferior margin. Parenchymal echotexture is homogeneous with normal echogenicity. No focal lesion is identified. Intrahepatic biliary radicles are not dilated. Portal vein and hepatic veins are patent with normal flow.
Conclusion: Heptomegaly
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Heterogeneous lesion
Coarse echotexture (? Chronic Liver Diseases)
Liver shows coarse, heterogeneous echotexture with irregular parenchymal pattern. No focal SOL identified. Findings are suggestive of chronic parenchymal liver disease.
Chronic liver failure/Liver cirrhosis
Liver shows increased parenchymal echogenicity with coarse echotexture (fatty fibrotic pattern) and decreased definition of the portal vein wall. Features are suggestive of chronic liver disease / chronic liver failure or cirrhosis.
Acute liver failure
Liver shows irregular contour with diffuse heterogeneity of parenchymal echotexture giving a starry night appearance, along with posterior sound attenuation. Multiple ubiquitous hyperechoic and hypoechoic micro- and macronodules are noted. These features are compatible with fulminant hepatic failure.
Atrophy of Liver Segment
Volume loss and parenchymal thinning of [segment] — segmental atrophy.
Regenerative Nodules
Multiple small iso–mildly hypoechoic nodules on coarse background — regenerative nodules.
Post-Surgical/Transplant Changes type-i
Localized parenchymal atrophy with architectural distortion — post-surgical change.
Post-Surgical/Transplant Changes type-ii
Linear echogenic bands/scar — post-operative changes.
Post-Surgical/Transplant Changes type-iii
Well-defined adjacent fluid collection — post-surgical seroma/hematoma.
Focal SOL (indeterminate)
Right lobe of liver shows a focal heterogeneous lesion of indeterminate nature. Margins are ill-defined. No definite internal calcification or cystic change noted. Color Doppler shows minimal/absent internal vascularity. Features are indeterminate; recommend further evaluation with contrast-enhanced CT/MRI for characterization.
Section-I Topics about liver Pathology
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