What is the normal appearance of the liver on ultrasound (US)?

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Normal Appearance of the Liver on Ultrasound

The normal liver on ultrasound appears with homogeneous echogenicity similar to or slightly higher than the renal cortex, with clear visualization of intrahepatic vessels, portal veins, and the diaphragm.

Echogenicity and Texture

  • Normal liver parenchyma shows echogenicity similar to or just higher than normal renal cortex 1
  • The liver should have a homogeneous texture without focal lesions 2
  • Intrahepatic vessels and portal veins should be clearly visible 1
  • The diaphragm should be clearly defined 1

Liver Surface and Contour

  • The normal liver surface should appear smooth without nodularity 2, 3
  • The liver edge should be sharp rather than rounded 2
  • Vessels should traverse through the liver parenchyma without distortion 1

Comparison with Abnormal Findings

Understanding normal appearance helps identify pathological changes:

Fatty Liver (Steatosis)

  • Increased echogenicity compared to renal cortex 1
  • Graded as mild, moderate, or severe based on:
    • Mild: mild diffuse increase in liver echogenicity with clear definition of diaphragm and intrahepatic vessel walls 1
    • Moderate: mild diffuse increase in liver echogenicity with obscuration of diaphragm and intrahepatic vessel walls 1
    • Severe: marked increase in liver echogenicity with non-visualization of diaphragm and intrahepatic vessel walls 1
  • US has 84.8% sensitivity and 93.6% specificity for moderate to severe hepatic fat deposition (>30% by histology) 1

Cirrhotic Liver

  • Nodular liver surface, especially on the undersurface (sensitivity 86%) 1
  • Rounded liver edge 2
  • Coarse parenchymal echotexture 4
  • Regenerative nodules may appear as hypoechoic nodules in liver parenchyma 2
  • Sensitivity of 65-95% for detection of cirrhosis, with positive predictive value of 98% 1

Common Pitfalls in Liver Ultrasound Interpretation

  • Normal liver echogenicity can vary slightly between individuals 5
  • Increased echogenicity alone cannot reliably diagnose fibrosis or cirrhosis 5
  • Fatty liver can mask underlying focal lesions due to increased background echogenicity 1
  • Technical factors such as gain settings can artificially alter the apparent echogenicity 1
  • The "reverse target sign" (isoechoic to hyperechoic centers surrounded by hyperechoic rim) may help differentiate cirrhotic nodules from other nodular liver lesions 6

Clinical Significance

  • Ultrasound is recommended as the initial diagnostic test of choice in patients with suspected liver disease 1
  • Normal liver ultrasound has high negative predictive value (91.5-95%) for excluding significant liver pathology 1, 3
  • Comparison with kidney echogenicity (hepatorenal index) provides a more objective assessment of liver echogenicity 1

References

1
Guideline

Guideline Directed Topic Overview

Dr.Oracle Medical Advisory Board & Editors, 2025

2
Research

[Ultrasonography in the diagnosis of liver cirrhosis].

Nihon rinsho. Japanese journal of clinical medicine, 1994

5
Research

Increased liver echogenicity at ultrasound examination reflects degree of steatosis but not of fibrosis in asymptomatic patients with mild/moderate abnormalities of liver transaminases.

Digestive and liver disease : official journal of the Italian Society of Gastroenterology and the Italian Association for the Study of the Liver, 2002

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Professional Medical Disclaimer

This information is intended for healthcare professionals. Any medical decision-making should rely on clinical judgment and independently verified information. The content provided herein does not replace professional discretion and should be considered supplementary to established clinical guidelines. Healthcare providers should verify all information against primary literature and current practice standards before application in patient care. Dr.Oracle assumes no liability for clinical decisions based on this content.

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