Ultrasound answers "is it there, is it solid, is the background liver abnormal" — it rarely answers "what is it".
Orient first
- Ultrasound is the detection and surveillance tool. In a cirrhotic surveillance programme it is the study that finds the lesion; it is not the study that characterises it.
- ECHOGENICITY is suggestive, never diagnostic. A uniformly hyperechoic lesion with posterior enhancement in a normal liver suggests haemangioma; the identical appearance in a fatty liver can be a metastasis standing out against bright background, and a small hepatocellular carcinoma can look exactly like a haemangioma.
- A HYPOECHOIC HALO around a lesion is the finding that should raise malignancy, particularly with multiple lesions.
- The BACKGROUND matters as much as the lesion: a coarse, nodular, shrunken liver with a recanalised umbilical vein and splenomegaly changes the differential completely before the lesion is described at all.
Acquire the study
- Fasted where possible; intercostal and subcostal windows, both in quiet respiration and on held inspiration.
- Place the focal zone AT the lesion depth and set the gain against a known fluid reference before judging echogenicity.
- Assess the whole liver systematically before dwelling on one lesion — a solitary lesion and multifocal disease are different diseases.
The manoeuvre
- Describe the background liver first: size, surface (smooth or nodular), echotexture, and deep penetration.
- For the lesion: segment, size in three planes, echogenicity against adjacent liver at the SAME depth, margin, and a halo if present.
- Assess posterior features — enhancement suggests fluid content, shadowing suggests calcification or fibrosis.
- Apply colour and power Doppler at LOW-flow settings and describe the pattern: peripheral, central, basket, spoke-wheel, or absent.
- Assess the portal vein for patency, direction of flow and any tumour thrombus — the finding that changes staging immediately.
- Look at the spleen, for varices and for ascites, which establish portal hypertension.
- State explicitly that characterisation requires multiphase CT or MRI, and recommend it.
What confirms it
- A confident diagnosis needs a characteristic pattern on an ADEQUATE study, in a patient whose background risk is known.
What licenses you to exclude it
- ⚠️ A single-phase study cannot characterise a liver lesion. If only a portal venous phase exists, report the lesion as uncharacterised and name the multiphase study needed — do not offer a differential as though it were an answer.
- Sub-centimetre lesions in a low-risk liver are usually too small to characterise; say that rather than calling them benign.
The classic misread
- Calling an echogenic lesion a haemangioma in a fatty liver, where the contrast is a background artefact.
- Missing tumour thrombus by never putting colour on the portal vein.
- Reporting a lesion without describing whether the background liver is cirrhotic.