Diffuse hepatic steatosis

Diffuse hepatic steatosis, also known as fatty liver, is a common imaging finding and can lead to difficulties assessing the liver appearances, especially when associated with focal fatty sparing.


Diffuse hepatic steatosis is common, affecting ~25% of the population. 


Hepatic steatosis is due to the abnormal accumulation of lipids, particularly triglycerides within hepatocytes 3-4. These are found in both small and large vesicles. Macroscopically, the liver is enlarged, yellow and greasy. Steatosis can lead to fibrosis and cirrhosis


Diffuse hepatic steatosis is often idiopathic. However, it may be associated with 1:

Radiographic features

General features include:

  • mild hepatomegaly (in ~75%) 5
  • attenuation/signal of liver shifted towards that of fat 
  • focal fatty sparing
    • islands of normal liver tissue within a sea of hepatic steatosis 
    • possibly occur due to regional perfusion differences 2 
    • importantly, compared to intrahepatic masses, fatty sparing has no mass effect with no distortion of vessels 
    • see also focal hepatic steatosis

Radiolucent liver sign: liver soft-tissue outline difficult to appreciate 5.


Steatosis manifests as increased echogenicity and beam attenuation 2,12. This results in:

  • renal cortex appearing relatively hypoechoic compared to the liver parenchyma (normally liver and renal cortex are of a similar echogenicity)
    • increased echogenicity relative to the spleen, when there is parenchymal renal disease
  • absence of the normal echogenic walls of the portal veins and hepatic veins
    • important not to assess vessels running perpendicular to the beam, as these produce direct reflection and can appear echogenic even in a fatty liver
  • poor visualisation of deep portions of the liver
  • poor visualisation of the diaphragm

Sono-elastography: can assess the degree of accompanying fibrosis by measuring tissue stiffness (Fibroscan, Acoustic Radiation Force Impulse) 10.


Steatosis causes reduced liver attenuation. This results in:

  •  low hepatic attenuation compared with spleen on non-contrast imaging
    • non-fatty liver is normally 6-12 HU greater density than spleen 5
    • if the attenuation of the liver is at least 10 HU less than that of the spleen the diagnosis of fatty liver is made 11
    • arterial phase or portal venous phase scans should not be used as the spleen enhances earlier than the liver due to predominant systemic arterial supply. Fatty liver can be diagnosed by contrast-enhanced CT if absolute attenuation is less than 40 HU, but this threshold has limited sensitivity 11
  • relatively hyperattenuating intrahepatic vessels

Requires both in-phase (IP) and out-of-phase (OOP) imaging to be adequately assessed 1. Fatty liver appears:

  • T1: hyperintense
  • T2: mildly hyperintense
  • IP/OOP imaging
    • signal drop out in fatty liver in out of phase greater than 15%

Of note, on IP/OOP imaging, the maximum signal loss occurs when there is 50% fatty infiltration of the liver. In situations in which there is >50% fatty infiltration, the out-of-phase sequence paradoxically becomes less hypointense than at 50%. This happens because there are relatively fewer water molecules to cancel out the fat signal. Chemical shift artifact at the parenchyma-vessel interface aids in detecting this situation 13.

Other MR uses:

  • MR spectroscopy: accurate quantitative non-invasive assessment of hepatic steatosis 8
  • MR elastography: shows promise as a method for assessing accompanying hepatic fibrosis 9
Nuclear medicine
  • Tc99m sulfur colloid 
    • uptake is reduced in fatty liver 5
    • reduced hepatic uptake relative to the spleen (reversal of normal liver: spleen uptake)
    • focal fatty area can simulate a hepatic mass 7
  • Xenon133: accurate quantitative non-invasive assessment of hepatic steatosis 8
  • FDG-PET: liver uptake is not altered by the presence of steatosis 6

Treatment and prognosis

As long as hepatic fibrosis and cirrhosis have not developed, fatty change is reversible with modification of the underlying causative factor, e.g. alcohol, pregnancy, obesity, diet.

Practical points

  • there is potential for missing mild hepatic steatosis on ultrasound if there is concurrent chronic renal disease, which increases the echogenicity of the kidneys. If there is any question that the patient may have a chronic renal disease, comparison of the left kidney with the spleen may be useful
  • a greater echogenicity difference between the right kidney and the liver than between the left kidney and the spleen is indicative of hepatic steatosis 12
  • if the attenuation of the liver on CT is at least 10 HU less than that of the spleen the diagnosis of fatty liver is made 11
  • MRI IP/OOP imaging shows a signal drop out in fatty liver greater than 15%​

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