Hyperechoic liver lesions

Last revised by Dr Daniel J Bell on 04 Nov 2021

A hyperechoic liver lesion on ultrasound can arise from a number of entities, both benign and malignant. A benign hepatic hemangioma is the most common entity encountered, but in patients with atypical findings or risk for malignancy, other entities must be considered.



The presence of hyperechogenicity can be a result of fat within a liver lesion 2, although some non-fat-containing lesions may also be echogenic (e.g. hepatic hemangioma).

Some suggest pulse inversion harmonic imaging with quantitative evaluation as being useful in facilitating the differential diagnosis of hyperechoic focal liver lesions, where a lesion-liver ratio of ≥1 being predictive of a benign nature, assuming that malignant lesions show a ratio of <1 1.

If a single, well-defined, homogeneous, echogenic mass <3 cm is found in an asymptomatic patient, without a history of malignancy and without risk factors for liver tumors, then a diagnosis of hemangioma can be made on ultrasound without the need for another test 5. If an appropriate clinical history is not available, then a wider differential is appropriate.

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Cases and figures

  • Case 1: hepatic hemangioma
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  • Case 2: focal hepatic steatosis
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  • Case 3: hepatic adenoma
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  • Case 4: steatohepatitic hepatocellular carcinoma
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  • Case 5: focal nodular hyperplasia
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