Focal hepatic steatosis

Last revised by Dr Daniel J Bell on 20 Oct 2021

Focal hepatic steatosis, also known as focal hepatosteatosis or focal fatty infiltration, represents small areas of liver steatosis. In many cases, the phenomenon is believed to be related to the hemodynamics of a third inflow.  

The term 'fatty infiltration of the liver' is often erroneously used to describe liver steatosis. Since fat is intracellular in liver steatosis, and not in the extracellular matrix, using infiltration to describe it is factually incorrect.

Essentially the same as those that contribute to diffuse hepatic steatosis:

  • diabetes mellitus
  • obesity
  • alcohol abuse
  • exogenous steroids
  • drugs (amiodarone, methotrexate, chemotherapy)
  • IV hyperalimentation

In general, the treatment of the underlying condition will reverse the findings.

A characteristic location for focal fatty change is the medial segment of the left lobe of the liver (segment 4) either anterior to the porta hepatis or adjacent to the falciform ligament. This distribution is the same as that seen in focal fatty sparing and is thought to relate to variations in vascular supply. This also would account for focal fatty change/sparing sometimes seen related to vascular lesions.

Ultrasound features only become apparent when the amount of fat reaches 15-20%. Features include:

  • increased hepatic echogenicity
  • hyperattenuation of the beam
  • mild or absent positive mass effect
  • geographic borders
  • no distortion of vessels
  • inability to visualize the portal vein walls (as the parenchyma is as bright as the wall)
  • decreased attenuation (non-contrast CT)
    • normal liver 50-57 HU
    • decreases by 1.6 HU per mg of fat in each gram of liver
  • decreased attenuation (post-contrast CT)
    • liver and spleen should normally be similar on delayed (70 seconds) scans
    • earlier scans are unreliable as the spleen enhances earlier than the liver (systemic supply rather than portal)

MRI is the imaging modality of choice in any case where the diagnosis is felt to be less than certain

  • increased T1 signal
  • signal drop-out on opposed-phase imaging
  • ability to quantify the fat fraction

When located in characteristic locations then there is usually little difficulty in making the correct diagnosis. If unusual in location or appearance then differentials to be considered include:

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Cases and figures

  • Case 1: ultrasound
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  • Case 1: T1 Gad FS
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  • Case 2: out of phase
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  • Case 3
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  • Case 4
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  • Case 5: with lobar distribution pattern
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  • Case 6: absent vessel distortion
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  • Case 7: focal hepatic steatosis
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  • Case 9
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  • Case 10: CEUS
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