Presentation
Abdominal distension and elevated liver function tests.
Patient Data
The liver exhibits a coarse and heterogeneous echo pattern, displaying right lobe atrophy and left lobe hypertrophy with a macronodular surface, indicating cirrhotic changes. Numerous hyperechoic avascular nodules are present, along with an exophytic, well-defined, heterogeneous rounded mass lesion in the lower portion of the right lobe, measuring about 6.1 x 6.5 cm and containing intralesional fat content. A dilated, thrombosed intra and extrahepatic portal vein is observed without detectable color Doppler flow. The gallbladder displays diffuse wall thickening with internal sludge. The common bile duct is not dilated.
Shear wave elastography, conducted using GE Logic E10s, reveals a shear wave velocity of about 2.39 m/s and kPa of 17.12, indicating a Metavir score of F4 (cirrhosis). The main hepatic artery's resistance index is approximately 0.82, with a peak systolic velocity of about 195 cm/s. Massive abdominopelvic ascites is evident.
The spleen is enlarged, measuring about 13.5 cm, with multiple hyperechoic foci suggesting gamma gandy bodies.
Dilated anterior abdominal wall varicose veins are also visible.
Case Discussion
Any mass lesion on a background of a cirrhotic liver must be considered hepatocellular carcinoma until proven otherwise.
Shear wave elastography is an imaging technique that quantifies tissue stiffness by measuring the speed of shear waves in tissue. If the velocity in the liver is more than 1.99 m/s, this indicates cirrhosis.
The hepatic arterial resistive index is used for hepatic arterial evaluation, with the usual normal range between 0.55 and 0.8. The mean hepatic arterial peak systolic velocity (PSV) is 103 cm/s.
Recanalization of the paraumbilical vein is diagnostic of portal hypertension.
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