Starry sky appearance (ultrasound)

Last revised by Yuranga Weerakkody on 2 Apr 2024

A starry sky appearance, also known as a centrilobular pattern 7, refers to a sonographic appearance of the liver parenchyma with 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. It was first introduced by Kurtz A in 1980 to describe a distinct pattern observed in liver imaging 8.


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 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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