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CASE PRESENTATION
By: Dr. SHAMSHAD KHAN TMO Radiology HMC
Case A 23 year old female came with
pain in right hypochondrium. LFT’s were normal Ultrasound abdomen was done Which is as …….
Diagnosis ?
Polycystic liver disease
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
LIVER LESIONS on ULTRASOUND Two main types
. Benign lesions
. Malignant lesions
BENIGN
Cystic which may be• Simple Cysts• Abscesses• Parasitic cysts
Cont……
Hepato-Billiary Cystic lesions
• Hemangioma• Caroli’s disease• Peliosis• Choledochal cyst• Veno -occlusive disease
Cont………
Hepatocellular
• Focal Nodular Hyperplasia• Adenoma
MALIGNANT Hepatocellular carcinoma Fibrolamellar HCC Metastasis Lymphoma Hepatoblastoma
CYSTS Most common lesions Have three main characteristics Anechoeic lumen Increased through transmission Well enhanced posterior wall
cont….
Simple Cyst
Simple Cyst with internal haemorrhage
May be multiple as in poly cystic liver
Cysts may be complex if they have Internal echoes Thick wall Septations Calcification
cont………
Complex cysts include Hematomas Abscesses Echinococcus Hemorrhagic tumors
Abscesses May be Bacterial , Fungal or
amoebic
Bacterial abscesses are caused due to intestinal infection like appendicitis and diverticulitis or even caused by endocarditis.
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
Abscess
Multiple Abscesses
Ruptured Liver Abscess
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
Amoebic liver abscess Initial stage
Amoebic liver abscess Recently formed cyst
Amoebic abscess of duration
Fungal Abscesses usually occur in
immunocompromised patients Most common organism is candida Mostly cause very small lesions
(microabscesses) Larger lesions may occur
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.
Ultrasound features of hepatic candidiasis “Wheel within a wheel”
peripheral hypoechoeic areainner echogenic wheelcentral hypoechoeic nidus
Bull’s eyeHyperechoeic centreHypoechoeic rim
Uniformly hypoechoeicprogressive fibrosis
Echogeniccalcification representing scar formation
Multiple hypoechoeic lesions in acute mylogenous leukemia
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
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 syndromeassociated with hypertension and congenital hepatic syndrome
Caroli’s disease with multiple intra hepatic cysts
Caroli disease in 9 year old girl
Choledochal cyst Congenital disease causing cystic
dilatation of bile ducts Appears in 1st year of life with
jaundice and sometimes with palpable mass
Choledochalcyst in 1 yearold boy
Choledochal cyst
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.
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.
Hydatid cyst
Hydatid Cyst withDetached membranes
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
cont………
If small, they are asymptomatic But if large, they have symptoms
due to mass effect.
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
Hemangioma
Multiple Hemangiomas
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.
Reverse Target sign.
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.
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
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
FNH
cont……
On ultrasound they are isoechoeic May have target appearance D/Ds include Hemangioma Hepatic adenoma HCC Fibrolamellar Carcinoma
FNH
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
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
Adenoma
Adenoma
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
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
Metastatic lesion
Metastasis
Metastasis
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
cont………
May be solitary, mulifocal or diffuse and infiltrating
Typical lesion is large with scattered smaller satellite lesions
HCC
HCC
HCC in 8 yearold girl
Hypoechoeic lesion in solitary HCC
Lymphoma Usually occurs with
hepatomegalyspleenomegalylymphadenopathy
Mostly of Non Hodgkins variety Mostly are single but may be multiple Appear as hypoechoeic lesions
Lymphoma Solitary lesion
Lymphoma Multiple
lesions
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.
Thanks