Secondly, if you have a malignant thrombus in the portal vein, it will increase the diameter of the vessel. Findings of heterogeneous liver echogenicity and irregular surface correlated to liver cirrhosis with a sensitivity of 70.6%, specificity of 100%, positive and negative predictive values of 100% and 82.1% respectively, and accuracy of 87.5%. If you look at the images on the left and just would consider the T2W-images, what could be the cause of the central area of high signal? <2cm (from <5% in the 90s in Europe to > 30% today in Japan) with curative therapy exploration reveals their radial position. This could also be an adenoma, but HCC would be unlikely because they show a fast wash out. normal liver and the absence of the portal vessels . the necrotic area appears larger than at the previous examination. G. Scott Gazelle (Editor), Sanjay Saini (Editor), Peter R. Mueller (Editor). Diffuse heterogeneous enlargement of the liver can be seen as a specific pattern in . detected in cancer patients may be benign . distinguished. MRI usually is more sensitive in detecting fat and hemorrhage. [citation needed], Transarterial chemoembolization (TACE) is part of palliative therapies for HCC used in Some advocate surgical resection only when tumors are larger than 5 cm or when AFP levels are elevated, since these two findings are associated with higher risk of malignancy. hyperemia, presence of intratumoral air, ultrasound limitations (too deep lesion or the [citation needed], The ultrasound appearance is a well defined lesion, with very thin, almost unapparent [citation needed]. attenuation which make US examination more difficult. If you would describe the image on the left, you would use terms as: So these findings suggest liverabscesses especially because it's clustered. the circulatory bed during arterial phase and completely enhancement during portal venous Low density, so it may be cystic i.e fluid containing. diagnosis of benign lesion. It may Complete fill in is sometimes prevented by central fibrous scarring. ** TECHNIQUE **: Ultrasound images of the liver acquired. [citation needed], Ablative therapies are considered curative treatments for HCC together with surgical Oliver JH, Baron RL: State of the art, helical biphasic contrast enhanced CT of the liver: Technique, indications, interpretation, and pitfalls. This means that at times the differential between FNH and FLC will not be possible. [citation needed], The substrate on which the tumor condition develops (if the liver is normal or if there is evidence of diffuse liver disease) and arterial hyperenhancement and portal and late wash-out. [citation needed], Systemic therapies are procedures based on the affinity of certain molecules to inhibit either HCC is the most frequent abdominal malignancy worldwide and is especially common in Asia and mediterrean countries. US will show a FNH as a non specific ill-defined lesion. The case on the left proved to be HCC. Imaging features of FLC overlap with those of other scar-producing lesions including FNH, HCC, Hemangioma and Cholangiocarcinoma. metastases, hepatocellular carcinoma and hemangioma and the confusion between Conventional US appearance of metastases is uncharacteristic, consisting Then continue. staging, particularly when sectional imaging investigations (CT, MRI) provide methods or patient reevaluation from time to time. A similar appearance has been described with liver abscesses.Calcified metastases may shadow when they are densely echogenic (figure). therapeutic efficacy as early as possible. well defined, un-encapsulated area, with echostructure and vasculature similar to those of Vascular complications include thrombosis and stenosis of the hepatic artery, portal vein, or inferior vena cava, as well as hepatic artery pseudoaneurysms and celiac artery stenosis. Mortel K, Segatto E, Ros P. The Infected Liver: Radiologic-Pathologic Correlation. This behavior of intratumoral Then continue. The size varies from a few millimeters to more than 10 cm (giant hemangiomas). with good liver function. This is the hallmark of fatty liver. The importance of a non enhanced scan is demonstrated in the case on the left. At the time the article was last revised Jeremy Jones had no recorded disclosures. potential post-intervention complications (e.g. characteristic of moderate/poorly differentiated HCC, with low or absent fatty changes. They are high in numbers and have a more or less uniform distribution, involving all liver segments. They may be associated with renal cysts; in this case the disease and it is now currently used in tumor therapeutic evaluation. months. During venous and sinusoidal phase the pattern is hypoechoic, and Nevertheless, chronic Budd-Chiari syndrome may be difficult to differentiate from cirrhosis ( 8 ). after the procedure, including CEUS, can show apart from the character of the lesion any By looking at the other phases to see if the enhancing areas match the bloodpool, it is usually possible to differentiate these lesions. the central fluid is contrast enhanced. HCC consists of abnormal hepatocytes arranged in a typical trabecular pattern. Currently, local response to treatment is focused on tumor necrosis diagnosed by contrast These masses may be benign genetic differences or a result of liver disease. It means that the liver isn't homogeneous. are represented by the presence of portal venous signal type or arterial type with normal RI regarded as malignant until otherwise proven. This is because the lesion is made of these channels containing blood. acoustic enhancement phenomenon is seen, which strengthens the suspicion of fluid measurement of the tumor diameter (RECIST criteria) is not enough for therapy assessment. Hypervascular metastases are less common and are seen in renal cell carcinoma, insulinomas, carcinoid, sarcomas, melanoma and breast cancer. categories of cirrhotic liver nodules: regenerative, dysplastic (considered as premalignant 2 A distended or enlarged organ. This raises the importance of the operator and equipment dependent part of the ultrasound In addition, discrimination of synchronous lesions that have a Benign diagnosis In this situation a pronounced hepatomegaly occurs. Although CE-CT and/or MRI are considered the method of choice in post-therapy Ultrasonography (US) is the initial imaging modality of choice for detection and follow-up of early and delayed complications from all types of liver transplantation. In addition, a considerable risk of hemorrhage exists when biopsy is performed on these hypervascular tumors. asymptomatic but also can be associated with pain complaints or cytopenia and/or Coarse calcifications are seen in only 5% of patients. Calcification can be seen in metastases of colon, stomach, breast, endocrine pancreatic ca, leiomyosarcoma, osteosarcoma and melanoma. [citation needed]. ideal diet is plant based diet. Abstract Purpose: To assess the value of contrast-enhanced ultrasound (CEUS) for differentiating malignant from benign focal liver lesions (FLLs . Metastases can look like almost any lesion that occurs in the liver. Lipiodol retention mainly intratumoral, but also diffusely intrahepatic. Reference article, Radiopaedia.org (Accessed on 04 Mar 2023) https://doi.org/10.53347/rID-17361, {"containerId":"expandableQuestionsContainer","displayRelatedArticles":true,"displayNextQuestion":true,"displaySkipQuestion":true,"articleId":17361,"questionManager":null,"mcqUrl":"https://radiopaedia.org/articles/coarsened-hepatic-echotexture/questions/2403?lang=us"}, View Yuranga Weerakkody's current disclosures, see full revision history and disclosures, doi:10.1148/radiographics.20.1.g00ja25173, shoulder (modified transthoracic supine lateral), acromioclavicular joint (AP weight-bearing view), sternoclavicular joint (anterior oblique views), sternoclavicular joint (serendipity view), foot (weight-bearing medial oblique view), paranasal sinus and facial bone radiography, paranasal sinuses and facial bones (lateral view), transoral parietocanthal view (open mouth Waters view), temporomandibular joint (axiolateral oblique view), cervical spine (flexion and extension views), lumbar spine (flexion and extension views), systematic radiographic technical evaluation (mnemonic), foreign body ingestion series (pediatric), foreign body inhalation series (pediatric), pediatric chest (horizontal beam lateral view), neonatal abdominal radiograph (supine view), pediatric abdomen (lateral decubitus view), pediatric abdomen (supine cross-table lateral view), pediatric abdomen (prone cross-table lateral view), pediatric elbow (horizontal beam AP view), pediatric elbow (horizontal beam lateral view), pediatric forearm (horizontal beam lateral view), pediatric hip (abduction-internal rotation view), iodinated contrast-induced thyrotoxicosis, saline flush during contrast administration, CT angiography of the cerebral arteries (protocol), CT angiography of the circle of Willis (protocol), cardiac CT (prospective high-pitch acquisition), CT transcatheter aortic valve implantation planning (protocol), CT colonography reporting and data system, CT kidneys, ureters and bladder (protocol), CT angiography of the splanchnic vessels (protocol), esophageal/gastro-esophageal junction protocol, absent umbilical arterial end diastolic flow, reversal of umbilical arterial end diastolic flow, monochorionic monoamniotic twin pregnancy, benign and malignant characteristics of breast lesions at ultrasound, differential diagnosis of dilated ducts on breast imaging, musculoskeletal manifestations of rheumatoid arthritis, sonographic features of malignant lymph nodes, ultrasound classification of developmental dysplasia of the hip, ultrasound appearances of liver metastases, generalized increase in hepatic echogenicity, dynamic left ventricular outflow tract obstruction, focus assessed transthoracic echocardiography, arrhythmogenic right ventricular cardiomyopathy, ultrasound-guided biopsy of a peripheral soft tissue mass, ultrasound-guided intravenous cannulation, intensity-modulated radiation therapy (IMRT), stereotactic ablative radiotherapy (SBRT or SABR), sealed source radiation therapy (brachytherapy), selective internal radiation therapy (SIRT), preoperative pulmonary nodule localization, transjugular intrahepatic portosystemic shunt, percutaneous transhepatic cholangiography (PTC), transhepatic biliary drainage - percutaneous, percutaneous endoscopic gastrostomy (PEG), percutaneous nephrostomy salvage and tube exchange, transurethral resection of the prostate (TURP), long head of biceps tendon sheath injection, rotator cuff calcific tendinitis barbotage, subacromial (subdeltoid) bursal injection, spinal interventional procedures (general), transforaminal epidural steroid injection, intravenous cannulation (ultrasound-guided), inferomedial superolateral oblique projection, breast ultrasound features: benign vs malignant, certain bile duct tumors: will also usually show of accompanying biliary duct dilatation, diffusely infiltrating hepatic metastases, 1. Cirrhotic liver monitoring, Early hepatocellular carcinoma (Early HCC), Techniques for evaluating the efficiency of therapy, Ultrasound monitoring ablative therapies (alcoholization PEI, radiofrequency ablation RFA), Ultrasound monitoring of TACE therapy (transarterial chemoembolization), Ultrasound monitoring of systemic therapies, "[Sonographic diagnostics of liver tumors]", "Contrast-enhanced ultrasonography parameters in neural network diagnosis of liver tumors", https://en.wikipedia.org/w/index.php?title=Ultrasonography_of_liver_tumors&oldid=1076573293, detection and characterization of hepatic tumors, This page was last edited on 11 March 2022, at 20:00. Hepatobiliary and Pancreatic Radiology: Imaging and Intervention. Posterior from the lesion the The Echogenic Liver: Steatosis and Beyond Ultrasound is the most common modality used to evaluate the liver. Gadolineum enhanced MRI will reveal similar enhancement patterns as on CECT. [citation needed], In case of successful treatment, US monitoring using CEUS is performed every three It is composed of multiple vascular channels lined by endothelial cells. mass with irregular shapes, fringed, with fluid or semifluid content, with or without air inside. The diagnosis of FNH is based on the demonstration of a central scar and a homogeneous enhancement. Thus, during the arterial a very accessible procedure, although it has a high specificity. Hypovascular metastases are the most common and occur in GI tract, lung, breast and head/neck tumors. Ultrasound examination 24 hours are the absence of irradiation and its high sensitivity in tumor vasculature detection, [citation needed] . The lower images show a lesion that is visible on all images. venous and late phases, respectively hypervascular (neuroendocrine tumors, malignant Doppler examination contrast enhancement of a nodule within 12cm developed on a cirrhotic liver is sufficient On the left a typical FNH with a central scar that is hypodens in the portal venous phase and hyperdens in the equilibrium phase. The method It is composed of multiple vascular channels lined by endothelial cells. Hypervascular metastases have to be differentiated from other hypervascular tumors that can be multifocal like hemangiomas, FNH, adenoma and HCC. During late phase the appearance is isoechoic or . It develops secondary to If you only had the portal venous phase you surely would miss this lesion. presence of venous type Doppler flow which reflects the portal venous nutrition of the During this phase the center of the lesion becomes hypoechoic, enhancing the tumor Residual tumor tissue is evidenced at the periphery of There are three d. progressive disease, defined as 25% increase in size of one or more measurable lesions In this pattern, the liver has a heterogeneous appearance with focal areas of increased periportal echogenicity. mass. As per ultrasound scan report of today, it has been observed that "heterogeneous echotexture of liver with irregular nodular surface of concern for chronic liver parenchymal disease" and "mild ascites". oncologists since 2003 because it involves no irradiation and has no hepatic or renal toxicity, determined by two observations not less than 4 weeks apart; An "infiltrative" type is also described which is difficult to discriminate from liver nodular reconstruction in cirrhosis. US Approach to Jaundice in Infants and Children. CEUS allows guidance in areas of viable tissue This is however also a feature of HCC and large hemangiomas. [citation needed], US examination is required to detect liver metastases in patients with oncologic history. Residual tumor has poorly defined edges, irregular shape, to the experience of the examiner. that of contrast CT and MRI . Sometimes, especially for HCC treated by benign conditions. [citation needed], Gadolinium MRI examination is a procedure used more and more often, and its advantages successfully applied in the treatment of liver metastases, where surgical resection is Its development is induced by intake of anabolic hormones and oral contraceptives. Calcified liver metastases are uncommon. This can occur due to a number of reasons which include: conditions that cause hepatic fibrosis 1 cirrhosis hemochromatosis various types of hepatitis 3 particularly chronic hepatitis conditions that cause cholestasis CEUS investigation has real diagnosis value due to the typical behavior Now do not just concentrate on the images, where you see the lesions best. conditions) and tumoral (HCC). Asked for Male, 58 Years. Peripheral enhancement cannot replace CT/MRI examinations which have well established indications in oncology. On the other hand, CE-CT is also Facciorusso et al. tumor is asymptomatic but may be associated with right upper quadrant pain in case of Then continue. transonic suggesting fluid composition. metastases). Left posterior oblique positioning aids visualization of the right hepatic lobe, by allowing easier placement of the transducer along the right lateral or right posterior body wall. In these metastases the halo is most probably related to a combination of compressed normal hepatic parenchyma around the mass and a zone of cancer cell proliferation. At US, metastases may appear cystic,hypoechoic, isoechoic or hyperechoic. CT will show most adenomas as a lesion with homogeneous enhancement in the late arterial phase, that will stay isodense to the liver in later phases. An ultrasound scan (also known as sonography) is a noninvasive procedure. techniques, CEUS is the one that brought a significant benefit not only by increasing the molecules are currently the subject of clinical trials), followed by embolization of hepatic of hemangioma, ultimately prove to be hepatocellular carcinoma. They consist of sheets of hepatocytes without bile ducts or portal areas. It consists of selective angiographic catheterization of the differentiation and therefore with slower development. 3 Left untreated, continued fibrotic changes can lead to multilobular cirrhosis. US sensitivity for metastases The enhancement pattern is characterized by sequential contrast opacification beginning at the periphery as one or more nodular areas of enhancement. In the arterial phase there is enhancement, but not as dense as the bloodpool. Significant overlap is noted between the CT appearances of adenoma, HCC, FNH, and hypervascular metastases, making a definitive diagnosis based on CT imaging criteria alone difficult and often not possible. On dynamic contrast-enhanced MRi the characteristics of metastases are the same as for CECT. loop" or "nodule-in-nodule" appearance, hypoechoic nodules in a hyperechoic tumor. different against the general pattern of restructured liver either by different echogenity or by CT will show hemangiomas as sharply defined masses with the same density as the vessels on NECT and CECT. disease (vascular and parenchymal decompensation for liver cirrhosis, weight loss, lack of plays a very important role in monitoring the dysplastic nodules to identify the moment vasculature completely disappearing. This articleand the rest of the serieswill discuss ultrasound evaluation of specific abdominal organs/systems, including scanning principles, normal sonographic appearance, and identification of common abnormalities seen during ultrasound examination. These therapies are based on the Calcifications occur in 30-60% of fibrolamellar tumors. The prevalence of echogenic liver is approximately 13% to 20%. scar. Twenty-one of these patients had normal liver echoes on ultrasound, 5 exhibited increased echogenicity and 5 had heterogeneous echogenicity. Even on delayed images the density of a hemangioma must be of the same density as the vessels. On delayed images the capsule and sometimes septa demonstrate prolonged enhancement. Cirrhosis, hepatitis, fatty liver, etc. However if we look at the NECT on the right, we'll notice, that it is not enhancement that we're looking at. This will give a pseudo-cirrhosis appearance. So any cystic structure near the biliary tract in a patient, who recently has undergone a biliary procedure, is suspicious of a liver abces. Rarely, sizes can reach several centimeters, leading up to the substitution of a whole liver Their efficacy (captures CA in Kuppfer cells) against tumor parenchyma (does not contain Kuppfer cells, identification (small sizes, small number) is important to establish an optimal course of adenocarcinomas) with hypoechoic pattern during arterial phase, and similar during portal This is consistent with fatty liver. That is because cholangiocarcinoma has a varied morphology and histology. circulatory pattern, displace normal liver structures and even neighboring organs (in case of Most hemangiomas are detected with US. ADVERTISEMENT: Supporters see fewer/no ads. [citation needed], HCC appearance on 2D ultrasound is that of a solid tumor, with imprecise delineation, with heterogeneous structure, uni- or multilocular (encephaloid form). Some cholangiocarcinomas have a glandular stroma. for deep or small lesions. [citation needed], Generally, RN is not distinct from the surrounding parenchyma. (hepatocellular carcinoma and some types of metastases), have a heterogeneous structure Removing a tissue sample (biopsy) from your liver may help diagnose liver disease and look for signs of liver damage. treatment results, while other studies have shown the limitations of CEUS especially vessels having a characteristic location in the center of the tumor, within a fibrotic scar. FNH, in particular, may simulate FLC, since both have similar demographic and clinical characteristics. Many patients with cirrhosis have portal venous thrombosis and many patients with HCC have thrombosis. Typically HCC invades liver vessels, primarily the portal veins but also the hepatic veins . NAFLD is now recognized as the hepatic manifestation of the metabolic syndrome and is a major cause of liver-related morbidity and mortality. The method has been adopted by [citation needed], Hydatid liver cyst. investigations with other diagnostic procedures; at a size between 10 20mm two For this In the arterial phase we see a hyperdense structure in the lateral segment of the left lobe of the liver. The examination has an acceptable sensitivity which In otherwise healthy young women using oral contraceptives, adenoma is favored. They are very common and are seen in up to 50% of patients with cirrhosis. circulation are vascular density, presence of vessels with irregular paths and size, some of Unable to process the form. tumor may appear more evident. Curative therapy is indicated in early These early HCC's are very different from the large ones that we see in the non-cirrhotic patients. A heterogeneous liver may be a sign of a serious underlying condition, or it may be caused by reversible liver conditions like fatty liver disease. Only on the delayed images at 8-10 minutes after contrast injection a relative hyperdense lesion is seen. remaining liver parenchyma has a dual vascular intake, predominantly portal. [3], They can be single or multiple, with variable size, generally less than 20mm (congenital). Typically, these tumors are more difficult to see than fatty deposits because the difference between the cells in the tumor and regular liver cells may not be obvious on a CT scan. [citation needed], Given that TACE is indicated only for hyperenhanced lesions during arterial phase, CEUS Fifty-four patients undergoing endoscopic ultrasound . Characteristic 2D ultrasound appearance is that of a very well defined lesion, with sizes of 2-3 cm or less, showing increased echogenity and, when located in contact with the diaphragm, a "mirror image" phenomenon can be seen. The delayed enhancement in this lesion is due to fibrotic tissue in a cholangiocarcinoma and is a specific feature of these tumors. enhancement is slow, during several minutes, depending on the size of hemangioma and the lesions it is necessary to extend the examination time to 5 minutes or even longer. One should always keep in mind the risk of false positive results for HCC in case of Spiral CT scan remains the method of choice in monitoring cancer therapies because it efficiency is currently made by indirect assessing Lipiodol binding to the tumor using nonenhanced There are AJR 2003; ISO: 1007-1014. guided biopsy; at a size over 20mm one single dynamic imaging technique with Chemical-shift imaging showing loss of signal on out-of-phase images can confirm the presence of fat. [citation needed], Cirrhotic liver is characterized by the occurrence of nodules with different sizes and collection size and an indication regarding its topography inside the liver (lobe, segment). normal liver parenchyma. of circumscribed lesions, with clear, imprecise or "halo" delineation, with homogeneous or Always look how they present in the other phases and compare with the bloodpool and remember that rim enhancement is never hemangioma. . In terms of Richard Baron is Chair of Radiology at the University of Chicago and well known for his work on hepatobiliary diseases. Ultrasound of her liver showed patchy echogenic liver parenchyma. therapies initially after one month then after every 3 months post-TACE. Most liver metastases are multiple, involving both lobes in 77% of patients and only in 10% of cases there is a solitary metastasis. Doppler circulation signal. Their diagnosis is quite difficult and the criteria used for differentiation are often If the liver is hyperechoic due to steatosis, the hemangioma can appear hypoechoic (figure). the presence of arterio-arterial and arterio-venous shunts, lack or incompetence of arterial Tumor wash out at the end of the arterial phase allows the types of benign liver tumors. In a further 2 patients both increased echogenicity and heterogeneous parenchyma were found. clinical suspicion of abscess. However, continued high alcohol consumption can result in fatty liver disease, which can cause cirrhosis of the liver, an irreversible condition. The most common tumor that causes retraction besides cholangiocarcinoma is metastatic breast cancer. What can an ultrasound of the liver detect? Diagnosis and characterization of liver tumors require a distinct approach for each group of In 65% there are satellite nodules and in some cases punctate calcifications are seen. Although malignant transformation is rare, for this reason, surgical resection is advocated in most patients with presumed adenomas. Ultrasound of Abdominal Transplantation. CEUS exploration is indicated when a nodule is of progressive CA enhancement of the tumor from the periphery towards the center. In some cases this accumulation can assess the effectiveness of therapy and to detect other nodules. Whenever you see a small cyst-like lesion in a patient who recently underwent an ERCP, be very carefull to assume it is just a simple cyst. Ultrasound of the normal liver and gall bladder The different lobes of the liver cannot be defined on ultrasound unless peritoneal effusion is present. Tumor characterization using the ultrasound method will be based on the following elements: consistency (solid, liquid, mixed), echogenicity, structure appearance (homogeneous or heterogeneous), delineation from adjacent liver parenchyma (capsular, imprecise), elasticity, posterior acoustic enhancement CE-MRI as complementary methods. Bull's eye or target lesions is a common presentation of metastases. palliative therapies (TACE and sorafenib systemic therapy) and in the end stage only without any established signs of malignancy. presence of fatty liver) or lack of patient's cooperation (immediately after therapy). vasculature as a sign of incomplete therapy or intratumoral recurrence. focal nodular hyperplasia) or absent, with posterior acoustic enhancement effect (cysts), validated indications at this time, but with proved efficacy in extensive clinical trials The lesion can have different forms, most cases being oval and Clinically, HCC overlaps with advanced liver cirrhosis Appendicitis - Pitfalls in US and CT diagnosis, Acute Abdomen in Gynaecology - Ultrasound, Transvaginal Ultrasound for Non-Gynaecological Conditions, Bi-RADS for Mammography and Ultrasound 2013, Coronary Artery Disease-Reporting and Data System, Contrast-enhanced MRA of peripheral vessels, Vascular Anomalies of Aorta, Pulmonary and Systemic vessels, Esophagus I: anatomy, rings, inflammation, Esophagus II: Strictures, Acute syndromes, Neoplasms and Vascular impressions, TI-RADS - Thyroid Imaging Reporting and Data System, How to Differentiate Carotid Obstructions. When calcified liver metastases are revealed by CT in a patient with unknown primary tumor, colon cancer will be the most likely cause. Dr. Leila Hashemi answered Internal Medicine 22 years experience Liver ultrasound: The size is normal but Heterogeneity could be due to fatty liver. That parts of the liver differ. without portal invasion) and advanced stage (N1, M1, with portal invasion) undergo have malignant histology and up to 50% of hyperechoic lesions, with ultrasound appearance Moreover a central scar may be found in some patients with fibrolamellar hepatocellular carcinoma, hepatic adenoma and intrahepatic cholangiocarcinoma. Fat deposition within adenomas is identified on CT in only approximately 7% of patients and is better depicted on MRI. tumor enhanced areas, reflecting total tumor necrosis) and absence of other new lesions Spectral Doppler examination detects central arterial vessels and CFM When an ultrasound states it is minimally heterogeneous.it means its surface has a different echotexture.this could be that it is developing a more coarse appearance which means possible liver disease that has no known cause. The role of US is tool in the evaluation of liver enzyme abnormalities is abdominal ultrasound (US), with more in-depth evalua-tion by computed tomography (CT), magnetic resonance imaging (MRI)/magnetic resonance cholangiopancreatog-raphy (MRCP), or cholescintigraphy as detailed later. This pattern is commonly seen in colorectal cancer. The figure on the left shows such a case. compared PC-LB and EUS-LB methods in terms of diagnostic outcomes including accuracy and safety for both focal and parenchymal liver diseases . Other authors noticed the presence of an arterial flow with small frequency variations The key to the diagnosis in the lesion on the left is the fact that it is isoattenuating to normal liver in the portal venous phase and stays that way without a wash out on the delayed phase (not shown). or the appearance of new lesions. palpating the liver with the transducer the hemangioma is compressible sending When increased, they can compress the bile The liver is the most common site of metastases. concordant imaging procedures are necessary, supplemented if necessary by an ultrasound