Starry sky appearance (ultrasound)

Last revised by Dr Jeremy Jones on 20 Sep 2021

A starry sky appearance , also known as a centrilobular pattern 7, refers to a sonographic appearance of the liver parenchyma in which there are bright echogenic dots throughout a background of decreased liver parenchymal echogenicity. Although usually associated with acute hepatitis, this sign has been found to have poor sensitivity and specificity 4.


This ultrasound sign should not be confused with the similarly named starry sky appearance (MRI) seen in multiple biliary hamartomas and the milky way sign (MRI) seen in progressive multifocal leukoencephalopathy (PML). 


It is thought to occur due to the edematous swelling of hepatocytes with a resultant decrease in the hepatic echogenicity. The altered acoustic properties between the portal venous radicles and hepatic lobules cause sonographic accentuation of the venule walls.


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Cases and figures

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