Ultrasonography of Diffuse Liver Disease

A Review

David S. Biller, DVM, Brett Kantrowitz, DVM,

and Takayoshi Miyabayashi, BVS, MS

Radiographically, the liver may appear normal even if severely diseased. Ultrasonography can be an
important adjunct in the evaluationof diffuse parenchymal hepatic disease. Diffuse liver disease appears
ultrasonographically as a change in liver echogenicity from normal when compared with the renal cortex
or spleen. Diffuse liver disease can be characterized as either hyperechoic due to fatty change, steroid
hepatopathy, and cirrhosis or hypoechoic due to congestion, suppurative hepatitis, and lymphoma.
Ultrasonographic diagnosis of diffuse liver disease should be substantiated by biopsy and histopatho-
logic evaluation. (Journal of Veterinary Internal Medicine 1992; 6:71-76)

RADIOGRAPHICALLY,the liver may appear normal
when severely diseased. Radiographs can reflect liver
size and overall configuration, but rarely delineate the
cause of the size alteration,especially when there is gener-
alized disease. Emaciation or abdominal effusion may
prevent evaluation of the liver by radiography because of
poor abdominal visceral detail, whereas the presence of
effusion may, improve ultrasonographic visualization of
the liver.
Ultrasonography is useful in evaluating focal liver dis-
ease.'-5 Space-occupying lesions, such as primary and
secondary tumors, cysts, abscesses, and granulomas can
be readily observed. Besides detection of disease, sonog-
raphy is also an accurate noninvasive means for moni-
toring the progression of disease.6 The utility of ultra-
sound to document the presence and extent of nonfocal
or diffuse hepatocellular disease is poorly substantiated.
Diffuse liver disease implies an extensive disease process
that is anatomically poorly defined. Ultrasonography
has proven usefuI in evaluating the parenchymal struc-
ture of the liver in animals'-' and therefore ultrasonogra-
From the Department of Surgical Sciences (Biller), School of Veteri-
nary Clinical Sciences, University of Wisconsin-Madison, Madison,
Wisconsin, Veterinary Diagnostic Imaging (Kantrowitz), Fountain
Valley, California, and the Department of Clinical Sciences
(Miyabayashi),College of Veterinary Medicine, The Ohio State Univer-
sity, Columbus, Ohio.
Reprint requests: David S. Biller, DVM, Department of Veterinary
Clinical Sciences, College of Veterinary Medicine, the Ohio State Uni-
versity, 1935 Coffey Rd., Columbus, OH 43210.
71
phy can be an important adjunct to evaluate diffuse pa-
renchymal disease of the liver.
Discussion
The liver has an homogeneous parenchyma of medium
level echogenicity. One should assess overall liver echo-
genicity relative to the renal cortex (where the right renal
cortex is in close proximity to the caudate lobe of the
liver) (Fig. 1) and the spleen (Fig. 2). Usually, the liver
parenchyma is the same (isoechoic) or slightly more
echogenic (hyperechoic) than the renal cortex and less
echogenic than the spleen. Major alteration of this echo-
genic relationship suggests an abnormality in one or
more of these organs. The liver should have smooth,
sharp borders on an ultrasound scan. The hepatic
borders are most easily identified when ascites is present
(Fig. 3).
Many anechoic/hypoechoic tubular or round struc-
tures are seen in the liver. These represent the hepatic
and portal veins, and the caudal vena cava. The intrahe-
patic bile ducts and hepatic arteries are not imaged un-
less abnormally dilated. The portal vein is situated ven-
tral to the caudal vena cava in the area of the porta hepa-
tis. The portal vein can vary in size in response to
pressure changes within the thoracic cavity associated
with the respiratory cycle.7Portal veins are easily recog-
nized by their apparently echogenic walls, the result of
being surrounded by fatty and fibrous tissue (Fig. 4).7
This fibrofatty tissue accounts for most of the small lin-
 Journal of Veterinary
72 BILLER, KANTROWITZ, AND MIYABAYASHI Internal Medicine

FIG.1 . Longitudinal scan through the normal right kidney and Caudate FIG.3. Longitudinal Scan through the right kidney and caudate lobe of
lobe of the liver. The echogenicity of the liver and renal cortex are the the fiver. The anechoic area between liver and kidney represents ab
same; liver (L), kidney (K). dominal effusion. The caudal margin of the normal liver is sharp and
smooth.

ear (parallel) echogenicities seen throughout the hepatic

parenchyma. Intrahepatic portal veins are largest near
the porta hepatis where they are confluent with the main
portal vein. The hepatic veins drain blood from hepatic
sinusoids and transport it to the systemic circulation via
the caudal vena cava. They are easily recognized by their
position immediately caudal to the diaphragm, and by
the fact that they become larger as they approach the
caudal vena cava. In contrast to the portal veins, the
walls of the hepatic veins are not seen (Fig. 4). Occasion-
ally, major hepatic veins will have some increase in pe-
ripheral echogenicity where they enter the caudal vena
cava, but they are not as prominent as comparably sized
portal veins.
When evaluating an animal for liver disease an accu-
rate diagnosis is based on information obtained from the
history, physical examination, laboratory data, and
various abdominal imaging techniques. Few hepatic le-
sions either diffuse or focal have specific sonographic
features. When evaluating the liver for diffuse hepatic
disease, the following characteristics are evaluated: 1)

FIG.4. Longitudinal (A) and transverse (B) Scans of the liver, demon-
strating echogenic walls of a portal vein (PV). The hepatic vein (HV)
FIG.2. Longitudinal Scan through the normal spleen and liver. The appears to have no wall ultrasonographically;HV (straight arrow), PV
spleen is hyperechoic when compared with the liver. (curved arrow).
Vol. 6 * NO. 2. 1992 ULTRASONOGRAPHY OF DIFFUSE LIVER DISEASE
TABLE
1. Causes of Diffuse Liver Disease
Hepatomegaly Microhepatica
Steroid hepatopathy Fibrosis
Idiopathic lipidosis Cirrhosis
Diabetes mellitus Portosystemic shunt
Amyloidosis
Congestion
Inflammation
Neoplasia (lymphoma)
Nodular cirrhosis
Acute hepatitis
liver size and shape, 2) beam penetration, 3) parenchy-
mal echogenicity, 4)vascularity, and 5) ancillary abnor-
malities (abnormalities unassociated with the liver).
Liver Size
There are numerous causes of generalized hepatomegaly
(Table 1). When there is poor abdominal detail, the
changes in hepatic size may not be appreciated. Micro-
hepatica may be indicated by cranial displacement of the
stomach radiographically. There are three causes of mi-
crohepatica (Table l). Liver size is a subjective estima-
tion when evaluated ultrasonographically. Ultrasound
criteria for the limits of normal liver size have not been
established in small animals.' Subjective evaluation of
the liver size is usually based on ultrasound experience,
with confirmation from palpation and radiography. The
authors believe that a small liver is one with minimal
hepatic volume between the gastric shadow and the dia-
phragm. Small livers are difficult to image due to dis-
placement of the liver beneath the rib cage (lung shadow-
ing from intercostal windows) and a smaller window be-
hind the costal arch (stomach between ventral
abdominal wall and liver). A large liver has a large vol-
ume between the diaphragm and stomach (extends cau-
dally toward the central abdomen), and is generally eas-
ier to image. The enlarged liver has rounding of the cau-
dal ventral edge.
Beam Penetration and Parenchymal Echogenicity
Beam penetration and parenchymal echogenicity are
best evaluated with longitudinal and transverse scans on
the right side of the liver, incorporating the cranial pole
of the right kidney. This can be done from either a ven-
tral or right lateral (intercostal) imaging position. Pene-
tration is diminished if the number of echoes in the deep
part of the liver is markedly decreased compared to the
number in the superficial (portion closest to the trans-
ducer) liver parenchyma, using maximum far gain con-
trol. Slight decrease in echo intensity from the ventral to
dorsal part of the liver is accepted as normal (attenua-
tion).' Echogenicity of liver parenchyma is considered
increased if the echogenicity of the liver is much greater
73
than that of the right renal cortex, or greater or equal to
the echogenicity of the spleen. Early reports suggest that
the liver is abnormal if its echogenicity is anything other
than slightly greater than the renal ~ortex.~*~*'' A more
recent report" indicates that the liver is not necessarily
abnormal if its echogenicity is greater than the renal cor-
tex. The difference in echogenicities between the liver
and renal cortex vary depending on angle of the incident
sound beam and the transducer frequency. The expected
relationships in echogenicity may also be influenced by
renal disease, and the amount of subcutaneous fat.
Correlation of these diffuse echogenic changes with clini-
cal and laboratory findings is important since one may
not be able to tell in which organ the changes have oc-
curred (i.e., is the echogenicity of the liver abnormal and
the other organ(s) normal, or is the liver normal with the
other structures being affected).
The sonographer must be aware that changing the
time-gain compensation curve or the transducer can
produce scans of the liver with artificially increased or
decreased echogenicity of the hepatic parenchyma, simu-
lating diffuse parenchymal disease. Therefore, subtle
changes in hepatic parenchymal echogenicity can resem-
ble those produced by technical factors. By decreasing
the dynamic imaging range, one can make the image
grainy and increase the contrast. This increase in con-
trast may make differentiating echogenicities easier.
Diffuse parenchymal diseases most often affect the
liver microscopically, and as a result, may only be diag-
nosed sonographically in people at advanced stages of
involvement." A normal scan in these patients does not
preclude the presence of disease. Diffuse diseases are
harder to detect than focal processes, because the former
cause less distortion of normal hepatic architectural
landmarks. Diffuse hepatic diseases, such as fatty infil-
tration, cirrhosis, or venous congestion, do not produce
detectable opacity changes of the liver on survey radio-
graphs.
There are several causes of diffuse liver disease that
result in a change in echogenicity, either hyperechoic
[fatty change, steroid hepatopathy (iatrogenic and Cush-
ing's disease), cirrhosis] or hypoechoic (congestion, sup-
purative hepatitis, and lymphoma) when comparing he-
patic echogenicity to the renal cortex or spleen. A diag-
nosis of diffuse liver disease made by ultrasound should
always be substantiated by biopsy.
Fatty change refers to the accumulation of excess fat
within the parenchymal cells of the liver, occumng as an
idiopathic condition in cats as well as secondary to dia-
betes mellitus, overnutrition, starvation, hepatotoxins,
and other metabolic disease^.'^,'^ Fatty infiltration of the
liver may cause a fine, diffusely increased echogenicity
(Fig. 5) and hepat~megaly.~,",'~,'~ Increased attenuation
of echos in the deep portion of the liver may occur with
severe (Fig. 5). Mild disease may show no
echo change. The majority of people with histologically

74 BILLER, KANTROWITZ, AND MIYABAYASHI
FIG.5. Longitudinal scan through the right kidney and caudate lobe of
the liver. The liver is markedly more echogenic (hyperechoic)than the
adjacent renal cortex. There is marked attenuation of echoes in the
deep portion of the liver. Histopathologic diagnosis was feline idio-
pathic hepatic lipidosis.
moderate or severe fatty infiltration of the liver have
brightly reflective echo patterns on u l t r a ~ o u n d . ~The
'~~~
high level echoes may be due to an increase in collagen
rather than fat." Ultrasound is able to detect fatty infil-
tration of the liver in 60% of people." The sensitivity of
detection by recognition of a bright liver pattern was re-
lated to the degree of infiltration and increased to 90%
with moderate to severe disease, but only 30% of people
with mild fatty infiltration had a bright echo pattern.15
The range of echogenic changes seen with fatty infiltra-
tion is similar to that seen kith cirrhosis. However, fatty
infiltration usually demonstrates hepatomegaly and a
smooth liver border, in comparison to a small irregular
liver with cirrhosis.
FIG.6. LongitudinalScan through the right kidney and markedly irregu-
lar caudate lobe of the liver. Anechoic area represents abdominal effu-
sion. Irregular hepatic margin and abdominal efision led to the pre-
biopsy diagnosis of cirrhosis with macronodular hyperplasia. Ultraso-
nographic biopsy was done. Histopathologic diagnosis was nodular
hyperplasia. Irregularity of cranial kidney pole is an artifact.
Journal of Veterinary
Internal Medicine
FIG.7. Longitudinal scan through the right kidney and caudate lobe of
the liver. Liver is hypoechoic compared to the adjacent renal cortex.
Histopathologic diagnosis was suppurative hepatitis. Small anechoic
wedge shaped area between the kidney and liver represents abdominal
effusion.
Steroid hepatopathy can cause both hepatomegaly
and diffusely increased echogenicity in the liver. These
changes have been noted with both hyperadrenal corti-
cism and iatrogenic Cushings disease and are probably
due to hepatocellular accumulation of glycogen."
Cirrhosis is a diffuse process characterized by fibrosis
and atrophy of the liver. A cirrhotic liver with nodular
changes is not always small but does result in a highly
irregular hepatic margin (knobby protrusions). Regard-
less of liver size, the margin of the normal liver should be
smooth. Any irregularities or "bumps" on the surface of
the liver are pathologic. Micronodular change may be
detected in cirrhotic livers with ascites by imaging the
nodular hepatic surface with a transducer via the ascites
(Fig. 6). Beam penetration in cirrhotic liver is manifested
FIG. 8. Transverse scan through the liver demonstrating prominent
small portal vessels due to the relative decrease in liver parenchymal
echogenicity.Small linear echogenicities(arrows) represent portal vein
walls.
Vol. 6 . NO.2,1992 ULTRASONOGRAPHY OF DIFFUSE LIVER DISEASE
FIG.9. Longitudinal scan through the right kidney (RK) and caudate
lobe of the liver. The caudal edges of the liver are rounded (consistent
with hepatomegaly)comparedwith the normal sharp margins noted in
Figure 3. The liver is markedly less echogenic than the adjacent renal
cortex. Histopathologic diagnosis of the liver was hepatic congestion.
Echocardiography revealed pericardial effusion with secondary cardiac
tamponade (end diastolic collapse of the right atrium and ventricle).
by an increased echogenicity ventrally (superficially)and
markedly diminished echoes dorsally ( d e e ~ )The . ~ over-
all liver echogenicity is increased with fewer observations
of the small peripheral vessels in the li~er.','~*'~
Increased
echogenicity of the liver parenchyma in patients with
cirrhosis is attributed to an increase in the amount of
collagen in the liver.g Two ancillary changes that may
occur ultrasonographically with cirrhosis are splenome-
galy and ascites due to portal hypertension.' Splenome-
galy is a subjective change as is the increase in size of the
portal and splenic veins. Pulsed Doppler ultrasound has
been used to demonstrate that experimentally induced
FIG. 10. Transverse scan through the liver demonstrating dilated he-
patic veins (HV) secondary to cardiac tamponade;CdVC (caudal vena
cava).
75
FIG. 1 1 . Longitudinal scan through the right kidney and caudate lobe
of the liver. The liver is less echogenic (hypoechoic) than the adjacent
renal cortex. Histopathologic diagnosis was hepatic lymphosarcoma.
hepatic cirrhosis has vascular changes including a de-
creased mean portal blood flow and decreased velocity.
Hepatitis is broadly defined as a diffuse inflammation
of the liver. In suppurative hepatitis, the liver echogeni-
city is decreased (Fig. 7). The walls of the small portal
veins are bright or more prominent than (Fig.
8). A previous study in patients identified a close correla-
tion between the severity of clinical signs, pathologic se-
verity, and ultrasound changes in acute hepatitis.
Normal ultrasound scans are common in minimally af-
fected livers. Sonographicchanges are believed to be due
to swelling of the hepatocytes.
Hepatic congestion is seen ultrasonographically as a
large liver (rounding of the caudoventral edge) (Fig. 9),
with decreased echogenicity (which may be due to di-
lated hepatic sinusoids),enlarged hepatic veins, and cau-
dal vena cava1,2(Fig. lo), and ascites. These sonographic
findings may contribute to the diagnosis of right heart
failure, pericardial disease, or heartworm disease.
Three sonographic patterns of hepatic lymphosar-
coma in the canine have been r e p ~ r t e dThese
. ~ patterns
are: 1) normal to slight reduction in hepatic echogenicity
(compared with the renal cortex) (Fig. 1I), 2) anechoic
or hypoechoic poorly marginated lesions, and 3) multi-
ple round, echodensities surrounded by areas of de-
creased e~hogenicity.~
A change in overall liver echo amplitude can be used
as a disease criterion, but visual assessment of general-
ized change is subjective, imprecise, and dependent on
the experience of the sonographer and the equipment
quality. Quantification of echo amplitude will eliminate
the problems of subjective visual interpretation. By as-
signing numerical values to echoes received from the
liver parenchyma, the results from any individual pa-
tient can be compared with a predetermined range of
normal values. Newer digital scan converters store the

76 BILLER, KANTROWITZ, AND MIYABAYASHI
amplitude values in a digital memory, making it possible
to retrieve this numerical information.20 This digital
conversion replaces visual judgment, but the technique
is only experimental at this time.
Ultrasonography of diffuse liver disease can noninva-
sively add information to the diagnostic evaluation of a
patient. The relative echogenicity of the liver must be
compared with a reference organ such as the renal cortex
of the right kidney or the spleen at the same depth and
instrument setting, assuming that these organs are
normal.
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1992 Veterinary Cancer Society
12th Annual Conference
October 18-21,1992
I
Asilomar Conference Center
A Unit of the California State Park System
Pacific Grove, CA
Contact: B. R. Madewell, Department of Veterinary Surgery, Building MS 1 -A, Room 2 1 12,
University of California, Davis, CA 95616-8745, (916) 752-3599.
Journal of Veterinary
Internal Medicine
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