CASE PRESENTATION
By:
Dr. SHAMSHAD KHAN
TMO Radiology
HMC
Case
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A 23 year old female came with pain in
right hypochondrium.
LFT’s were normal
Ultrasound abdomen was done
Which is as …….
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Diagnosis ?
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Polycystic liver disease
Polycystic liver disease
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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
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Two main types
Benign lesions
. Malignant lesions
.
BENIGN
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Cystic which may be
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Simple Cysts
Abscesses
Parasitic cysts
Cont……
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Hepato-Billiary Cystic lesions
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•
•
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Hemangioma
Caroli’s disease
Peliosis
Choledochal cyst
Veno -occlusive disease
Cont………
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Hepatocellular
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Focal Nodular Hyperplasia
Adenoma
MALIGNANT
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Hepatocellular carcinoma
Fibrolamellar HCC
Metastasis
Lymphoma
Hepatoblastoma
CYSTS
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Most common lesions
Have three main characteristics
Anechoeic lumen
Increased through transmission
Well enhanced posterior wall
cont….
Simple Cyst
Simple Cyst with internal
haemorrhage
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May be
multiple
as in
poly cystic
liver
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Cysts may be complex if they have
Internal echoes
Thick wall
Septations
Calcification
cont………
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Complex cysts include
Hematomas
Abscesses
Echinococcus
Hemorrhagic tumors
Abscesses
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May be Bacterial , Fungal or amoebic
Bacterial abscesses are caused due
to intestinal infection like appendicitis
and diverticulitis or even caused by
endocarditis.
Cont…
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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
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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
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Initial stage
Amoebic liver abscess
Recently
formed cyst
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Amoebic
abscess of
duration
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Fungal Abscesses
usually occur in immunocompromised
patients
Most common organism is candida
Mostly cause very small lesions
(microabscesses)
Larger lesions may occur
cont……
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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
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“Wheel within a wheel”
peripheral hypoechoeic area
inner echogenic wheel
central hypoechoeic nidus
Bull’s eye
Hyperechoeic centre
Hypoechoeic rim
Uniformly hypoechoeic
progressive fibrosis
Echogenic
calcification representing scar formation
Multiple
hypoechoeic
lesions in
acute
mylogenous
leukemia
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Hepato-Billiary Vascular Cysts
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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
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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 syndrome
associated with hypertension and congenital
hepatic syndrome
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Caroli’s disease
with multiple
intra hepatic
cysts
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Caroli disease
in 9 year old
girl
Choledochal cyst
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Congenital disease causing cystic
dilatation of bile ducts
Appears in 1st year of life with jaundice
and sometimes with palpable mass
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Choledochal
cyst in 1 year
old boy
Choledochal cyst
Parasitic cysts
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Usually caused by Ecchinococcus
granulosus
Liver is most commonly affected organ
Have an external membrane ectocyst
and an internal germinal layer called
endocyst.
cont……
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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 with
Detached
membranes
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BENIGN HEPATOCELLULAR
LESIONS
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Hemangiomas
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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………
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If small, they are asymptomatic
But if large, they have symptoms due to
mass effect.
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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……
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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.
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cont………
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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
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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………
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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……
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On ultrasound they are isoechoeic
May have target appearance
D/Ds include
Hemangioma
Hepatic adenoma
HCC
Fibrolamellar Carcinoma
FNH
HEPATIC ADENOMA
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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……
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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
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Adenoma
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Adenoma
MALIGNANT LIVER LESIONS
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Metastasis
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Liver and Lungs are most common sites for
metastasis
Multiple in 98% cases involving both lobes
LFTs are unreliable in most cases
cont………
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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
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Metastasis
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Metastasis
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HEPATOCELLULAR CARCINOMA
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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………
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May be solitary, mulifocal or diffuse and
infiltrating
Typical lesion is large with scattered
smaller satellite lesions
HCC
HCC
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HCC in 8 year
old girl
Hypoechoeic
lesion in
solitary
HCC
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Lymphoma
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Usually occurs with
hepatomegaly
spleenomegaly
lymphadenopathy
Mostly of Non Hodgkins variety
Mostly are single but may be multiple
Appear as hypoechoeic lesions
Lymphoma
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Solitary
lesion
Lymphoma
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Multiple
lesions
CONCLUSION
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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