Body Imaging – Liver

  • Liver Intro
  • Liver Contrast
  • Exam Protocol
  • Guidelines
  • Bibliography

CEUS is a safe, versatile and reliable tool for imaging the liver in the following clinical contexts:  

  • Characterization of focal liver lesions
  • Resolution of indeterminate masses from CT and MR scans
  • Guide interventional procedures
  • Follow-up interventional procedures
  • Assessment of liver vascularity
  • Monitor changes in enhancement pattern over time for selected LR-3 or LR-4 observations
  • Differentiate tumor in vein from bland thrombus

CEUS uses ultrasound contrast agents (UCAs)  to improve the clarity and reliability of conventional ultrasound scans. UCAs are comprised of liquid suspensions of biodegradable gas-filled microspheres (sometimes called “microbubbles”). When they are injected into a patient’s arm vein during an ultrasound exam, they flow through the body’s microcirculation without impediment, and are metabolized and expelled from the body within minutes.

Details on “how to” below:

Patricia C. Jo, MD Hyun-Jung Jang, MD Peter N. Burns, PhD Kelly W. Burak, MD Tae Kyoung Kim, MD Stephanie R. Wilson, MD

Integration of Contrast enhanced US into a Multimodality Approach to Imaging of Nodules in a Cirrhotic Liver: How I Do It
Radiology: Volume 282: Number 2—February 2017 317 – 331.

Commonly asked CEUS questions

Timing: Imaging and timer begins with the start of the saline flush. Continuous recording from the arrival of the first bubble in the FOV to just beyond the peak of maximum enhancement (approximately 20-60 sec). Stop imaging (leave transducer in place) and then follow with intermittent brief acquisitions (5-10 sec) every 30 or 60 seconds for up to 5-6 minutes. Shorter scanning may be appropriate if the lesion is fully characterized sooner. In the PVP and late phases, a sweep of the liver can be performed to evaluate for additional lesions (looking for wash-out). From the cine clips, still images can then be saved at the end of the study.

Tips: Utilize the shortest distance from the transducer crystal to the lesion to optimize the study. Consider supine and LLD patient positions and also subcostal and intercostal transducer placement. Imaging in the long axis of the patient will generally reduce out of plane images due to respiration. Practice breathing with the patient utilizing either quiet breathing or breath suspension in neutral position over full suspended inspiration.

Barr, R.G., Contrast enhanced ultrasound for focal liver lesions: how accurate is it? Abdom Radiol (2018) 43:1128–1133

Darge, K., et al., Safety of contrast-enhanced ultrasound in children for non-cardiac applications: a review by the Society for Pediatric Radiology (SPR) and the International Contrast Ultrasound Society (ICUS). Pediatr Radiol, 2013. 43(9): p. 1063-73.

Burns, P.N., S.R. Wilson, and D.H. Simpson, Pulse inversion imaging of liver blood flow: improved method for characterizing focal masses with microbubble contrast. Invest Radiol, 2000. 35(1): p. 58-71.

Wilson, S.R. and P.N. Burns, An algorithm for the diagnosis of focal liver masses using microbubble contrast-enhanced pulse-inversion sonography. AJR Am J Roentgenol, 2006. 186(5): p. 1401-12.

Burns, P.N. and S.R. Wilson, Focal liver masses: enhancement patterns on contrast-enhanced images–concordance of US scans with CT scans and MR images. Radiology, 2007. 242(1): p. 162-74.

Durot, I., S.R. Wilson, and J.K. Willmann, Contrast-enhanced ultrasound of malignant liver lesions. Abdom Radiol (NY), 2017.

Jang, H.J., T.K. Kim, and S.R. Wilson, Small nodules (1-2 cm) in liver cirrhosis: characterization with contrast-enhanced ultrasound. Eur J Radiol, 2009. 72(3): p. 418-24.

Jang, H.J., et al., Enhancement patterns of hepatocellular carcinoma at contrast-enhanced US: comparison with histologic differentiation. Radiology, 2007. 244(3): p. 898-906.

Jo, P.C., et al., Integration of Contrast-enhanced US into a Multimodality Approach to Imaging of Nodules in a Cirrhotic Liver: How I Do It. Radiology, 2017. 282(2): p. 317-331.

Claudon, M., et al., Guidelines and good clinical practice recommendations for Contrast Enhanced Ultrasound (CEUS) in the liver – update 2012: A WFUMB-EFSUMB initiative in cooperation with representatives of AFSUMB, AIUM, ASUM, FLAUS and ICUS. Ultrasound Med Biol, 2013. 39(2): p. 187-210.

Piscaglia, F., et al., The EFSUMB Guidelines and Recommendations on the Clinical Practice of Contrast Enhanced Ultrasound (CEUS): update 2011 on non-hepatic applications. Ultraschall Med, 2012. 33(1): p. 33-59.

Wilson, S.R., et al., Enhancement patterns of focal liver masses: discordance between contrast-enhanced sonography and contrast-enhanced CT and MRI. AJR Am J Roentgenol, 2007. 189(1): p. W7-W12.

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