Abnormal Liver Ultrasound

Abnormal liver ultrasound findings are very common.

Most are:

  • benign
  • incidental
  • non-urgent

A few require:

  • urgent imaging
  • specialist referral
  • or admission

Your job is to:

Recognise which findings are harmless
and which need action

Not panic over every abnormal report.

✅ First principle

Always ask:

Is this incidental or clinically significant?

Because:

  • Fatty liver → common, outpatient issue
  • Dilated bile duct + sepsis → emergency

Context matters more than the scan.

✅ Step 1 – Read the report properly

Focus on:

  • Liver texture
  • Size
  • Bile ducts
  • Gallbladder
  • Focal lesions
  • Ascites/spleen

These guide your next step.

🟡 Common findings and what they actually mean

🟢 Fatty liver / increased echogenicity

Report says:

  • “Fatty infiltration”
  • “Increased echogenicity”
  • “Hepatic steatosis”

Meaning:

Usually MASLD (fatty liver)

Very common:

  • obesity
  • diabetes
  • metabolic syndrome
  • alcohol

What to do:

  • Check LFTs
  • Assess metabolic risk
  • Lifestyle advice
  • Fibrosis risk assessment (FIB-4/FibroScan if needed)

Not urgent
No need for CT/MRI

This is the most common finding you’ll see.

🟡 Coarse echotexture / nodular liver

Meaning:

Possible chronic liver disease or cirrhosis

Think:

  • fibrosis
  • cirrhosis
  • portal hypertension

What to do:

  • LFTs
  • fibrosis assessment
  • refer hepatology
  • consider cirrhosis workup

Not emergency, but important.

Needs proper evaluation.

🔴 Dilated bile ducts / CBD dilatation

Report:

“CBD dilated” or “intrahepatic duct dilatation”

Meaning:

Obstruction until proven otherwise

Think:

  • gallstones
  • cholangitis
  • malignancy
  • stricture

If symptomatic (pain/fever/jaundice):

👉 urgent admission + antibiotics + MRCP/ERCP

If incidental:

👉 MRCP referral

This can be serious — don’t ignore.

🔴 Gallstones + symptoms

Symptoms:

  • RUQ pain
  • fever
  • jaundice

Think:

  • cholecystitis
  • cholangitis
  • pancreatitis

What to do:

👉 surgical/gastro referral

Symptomatic stones matter.
Asymptomatic stones usually don’t.

🟡 Ascites

Meaning:

Portal hypertension or malignancy

Think:

  • cirrhosis
  • cancer
  • heart failure
  • TB

What to do:

👉 ascitic tap
👉 workup cause

New ascites always needs investigation.

🔴 Focal liver lesion

Very common incidental finding.

Don’t panic — but don’t ignore.

Small simple cyst

Thin wall, black, well-defined

👉 benign
👉 no action

Haemangioma (typical appearance)

Common benign lesion

👉 usually no action

Indeterminate / solid lesion

Unknown mass

👉 needs CT/MRI liver
👉 refer

Especially if:

  • cirrhosis
  • cancer history
  • weight loss

Never dismiss these.

🟡 Hepatomegaly

Usually:

  • fatty liver
  • congestion
  • hepatitis

Check LFTs and history

Not urgent alone.

🟡 Splenomegaly

Think:

  • portal hypertension
  • chronic liver disease
  • haematology causes

If with liver changes → suspect cirrhosis

✅ Step 2 – Match scan to clinical picture

Ultrasound never interpreted alone.

Combine with:

  • symptoms
  • LFTs
  • alcohol history
  • metabolic risk
  • infection markers

Scan + bloods + story = diagnosis

✅ Practical ward/clinic scenarios

Scenario 1

Fatty liver, overweight diabetic, ALT mildly raised
→ MASLD
→ lifestyle + outpatient follow-up

Scenario 2

Dilated CBD + fever + jaundice
→ cholangitis
→ urgent admission

Scenario 3

Coarse liver + ascites
→ likely cirrhosis
→ hepatology referral

Scenario 4

Incidental 2 cm indeterminate lesion
→ CT/MRI liver

Scenario 5

Simple cyst
→ ignore

✅ When to escalate urgently

Urgent referral/admission if:

  • cholangitis features
  • obstructive jaundice
  • suspected malignancy
  • severe pain
  • decompensated cirrhosis
  • new ascites in unwell patient

Don’t manage these as routine.

❌ Common junior mistakes

  • Panicking over fatty liver
  • Ignoring dilated ducts
  • Not investigating new ascites
  • Over-investigating simple cysts
  • Missing liver disease signs
  • Referring every mild abnormality

Learn what matters.

✅ Simple ward rule

When you see abnormal ultrasound:

Ask:

  1. Obstruction?
  2. Mass?
  3. Cirrhosis/ascites?
  4. Or just fatty liver?

Only the first three usually need action.

✅ Take-home concept

Most abnormal liver ultrasounds are fatty liver and benign.
Obstruction, masses, and cirrhosis are the ones you must not miss.

Focus on those, and you’ll make safe decisions.