Hepatic hemangioma: atypical on ultrasound (hepatic steatosis)

Case contributed by Jan Frank Gerstenmaier


Asymptomatic patient, for follow up

Patient Data

Age: 55 years
Gender: Male

The liver remains of diffusely markedly increased echotexture in keeping with fatty infiltration.A few small regions of focal fatty sparing are seen, most prominent around the gallbladder and main portal vein. The known hypoechoic segment VI liver lesion is again demonstrated and is stable. It is well circumscribed and measures approximately 2.9cm in maximum dimension. No new liver lesion is seen. The main portal vein is not enlarged and demonstrates flow in a normal direction. No flow is seen within the ligamentum teres.

Conclusion Marked fatty infiltration of the liver with a stable, hypoechoic segment VI liver lesion, when compared to the prior examination.

MRCP for an unrelated reason


No intra or extrahepatic biliary dilation, with the common bile duct measuring less than 4 mm. No strictures or filling defects are identified. The gallbladder has a normal appearance, with no cholelithiasis identified.  The liver shows a significant drop in signal intensity on out of phase T1 imaging, consistent with fatty infiltration. There is focal fatty sparing at the gallbladder fossa.  A 2.3 x 1.9 cm T2 hyperintense lesion within segment 6 has been characterized as a hemangioma on multiphase CT and is unchanged in size. Three subcentimeter T2 hyperintense lesions are seen in segments 8 and 7, indeterminate on this study.

Conclusion: Severe hepatic steatosis. Stable segment 6 hemangioma. Indeterminate segment 8 and 7 lesions may be further hemangiomata or cysts.


The  liver is of increased echointensity throughout, consistent with fatty infiltration.  There is region of focal fatty sparing in the gallbladder fossa and this is more focal in one portion measuring approximately 3.6 cm in diameter.  There is a further discrete lesion in segment 6 of the liver.  This measures approximately 2.3 cm in diameter.  It is ovoid and hypoechoic with posterior enhancement.

It is non-specific in appearance and whilst it may represent focal fatty sparing, differential would include a cavernous hemangioma. Triple phase liver CT is recommended to elucidate this finding further. The biliary tree is normal without cholelithiasis. The common duct measures 2.6 mm.

Flow is evident in the main portal vein which is normal in size. No splenic or renal abnormality. The right kidney measures 10.6 cm and the left kidney measures 10.9 cm in bipolar length.

The spleen diameter is 8.4 cm.

Previous 3-Phase liver CT


Hypo dense mass in segment 6 demonstrates progressive peripheral nodular enhancement and fills in completely in delayed phase.

Hypoechoic liver hemangioma on background of hepatic steatosis

Case Discussion

The majority of liver hemangiomas are sharply circumscribed and hyperechoic at ultrasound. If there is diffuse fatty infiltration of the liver, the parenchyma can be of such increased echo intensity that a hemangioma appears hypoechoic, as in this case.

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