CASE PRESENTATION

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CASE PRESENTATION

• By
• Dr. SHAMSHAD KHAN
• TMO Radiology
• HMC

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Case

• A 23 year old female came with pain in right
  hypochondrium.
• LFTs were normal
• Ultrasound abdomen was done
• Which is as .

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• Diagnosis ?

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• Polycystic liver disease

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Polycystic liver disease

• About 10 to 13 of individuals have cysts in
  liver either single or multiple
• Mostly are asymptomatic
• LFTs are normal in most cases
• Approx 45 occur with polycystic kidney disease

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LIVER LESIONS on ULTRASOUND

• Two main types
• . Benign lesions
• . Malignant lesions

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BENIGN

• Cystic which may be
• Simple Cysts
• Abscesses
• Parasitic cysts

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Cont

• Hepato-Billiary Cystic lesions
• Hemangioma
• Carolis disease
• Peliosis
• Choledochal cyst
• Veno -occlusive disease

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Cont

• Hepatocellular
• Focal Nodular Hyperplasia
• Adenoma

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MALIGNANT

• Hepatocellular carcinoma
• Fibrolamellar HCC
• Metastasis
• Lymphoma
• Hepatoblastoma

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CYSTS

• Most common lesions
• Have three main characteristics
• Anechoeic lumen
• Increased through transmission
• Well enhanced posterior wall
• cont.

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Simple Cyst
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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

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Abscesses

• May be Bacterial , Fungal or amoebic
• Bacterial abscesses are caused due to
  intestinal infection like appendicitis and
  diverticulitis or even caused by endocarditis.

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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

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Abscess
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Multiple Abscesses
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Ruptured Liver Abscess
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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

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Amoebic liver abscess

• Initial stage

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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

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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.

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Ultrasound features of hepatic candidiasis

• Wheel within a wheel
• peripheral hypoechoeic area
• inner echogenic wheel
• central hypoechoeic nidus
• Bulls eye
• Hyperechoeic centre
• Hypoechoeic rim
• Uniformly hypoechoeic
• progressive fibrosis
• Echogenic
• calcification representing scar formation

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• Multiple
• hypoechoeic
• lesions in
• acute
• mylogenous
• leukemia

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Hepato-Billiary Vascular Cysts

• Hepato-Billiary Vasculature can also appear as
  Cysts as seen in
• Aneurysms
• Arterio-portal and Veno-portal fistulas
• Carolis disease
• Choledochal cyst

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Carolis 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 syndrome
• associated with hypertension and congenital
  hepatic syndrome

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• Carolis disease
• with multiple
• intra hepatic
• cysts

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• Caroli disease
• in 9 year old
• girl

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Choledochal cyst

• 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

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Choledochal cyst
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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.

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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.

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Hydatid cyst
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• Hydatid
• Cyst with
• Detached
• membranes

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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

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cont

• 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

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Hemangioma
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Multiple Hemangiomas
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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.

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• Reverse Target
• sign.

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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.

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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

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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

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FNH
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cont

• On ultrasound they are isoechoeic
• May have target appearance
• D/Ds include
• Hemangioma
• Hepatic adenoma
• HCC
• Fibrolamellar Carcinoma

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FNH
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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

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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

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• Adenoma

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• Adenoma

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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

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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

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Metastatic lesion
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• Metastasis

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• Metastasis

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• 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

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cont

• May be solitary, mulifocal or diffuse and
  infiltrating
• Typical lesion is large with scattered smaller
  satellite lesions

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HCC
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HCC
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• HCC in 8 year
• old girl

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• Hypoechoeic
• lesion in
• solitary
• HCC

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Lymphoma

• Usually occurs with
• hepatomegaly
• spleenomegaly
• lymphadenopathy
• Mostly of Non Hodgkins variety
• Mostly are single but may be multiple
• Appear as hypoechoeic lesions

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Lymphoma

• Solitary
• lesion

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Lymphoma

• Multiple
• lesions

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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.

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• Thanks