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

Hepato-Billiary Cystic lesions 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 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

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 syndrome associated with hypertension and congenital hepatic syndrome ia

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

Choledochal cyst in 1 year old 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 with Detached 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 year old girl

Hypoechoeic lesion in solitary HCC

Lymphoma Usually occurs with hepatomegaly spleenomegaly lymphadenopathy 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