Echogenic Liver: Meaning, Causes, And Diagnosis

Echogenicity is the ability of any inner part of the body to reflect sound waves, creating echoes during an ultrasound. An echogenic liver means the echoes reflected from an ultrasound appear whiter (brighter) than those from a normal liver. The liver's echogenicity indicates the presence of fat content or possible damage.

In most clinical settings, the prevalence of echogenic liver is around 13–20%, attributed especially to hepatic steatosis (fatty liver disease). Hepatic steatosis affects approximately 10–46% of the general population.¹ ²

What does echogenic liver mean (hyperechoic liver)?

Echogenic is how sound bounces back to form an image. Something in the liver with low echogenicity appears as a dark image, referred to as hypoechoic, while that with high echogenicity reflects bright light and is known as hyperechoic.

Generally, diffuse liver disease can be either hyperechoic due to fatty changes in the liver, cirrhosis, or steroid hepatopathy, or hypoechoic due to lymphoma, suppurative hepatitis, and congestion.

Hyperechoic liver lesions on an ultrasound can result from several entities that may be malignant and benign. An echogenic liver is commonly identified with hepatic steatosis (fatty liver disease).

How is the liver disease diagnosed?

To diagnose liver disease, your doctor will likely start by performing a physical exam and asking about your health history. After that, they will recommend an ultrasound test to check for liver attenuation.

Low and high attenuation values can indicate the presence of disease. Afterward, your doctor may recommend the following tests to complete the diagnosis:

Liver biopsy

This procedure is done by removing a tissue sample from the liver (biopsy) to help diagnose liver disease and check signs for the extent of the damage. The procedure uses a long needle inserted through the skin to extract a tissue sample. Then, it is sent to the lab for testing.

Blood tests

These help to diagnose liver disease. In some cases, doctors can use them to look for genetic conditions or specific liver problems. 

Imaging tests

Liver sonography, MRI, and CT scans are the primary imaging modalities to diagnose liver problems, such as lesions.

Finding the exact cause and the extent of damage is crucial in determining a treatment plan.

What are the causes of echogenic liver lesions?

Liver lesions can be malignant or benign. Most lesions are detected during imaging tests, and while most are benign, receiving a proper diagnosis is crucial.

Some possible causes of liver lesions include the following:

• Prolonged use of birth control pills

• Smoking

• Cirrhosis from chronic liver disease due to heavy drinking or due to hepatitis B or C

• Malformation of the liver

• Genetic mutations

• Present at birth or after echinococcus infection

• Extended use of anabolic steroids

While anybody can develop liver lesions, others are at a higher risk due to their medical condition, such as diabetes, hemochromatosis (iron buildup), cirrhosis, or lifestyle behaviors like being overweight, heavy alcohol use, smoking cigarettes, or eating food with aflatoxin.

Malignant lesions

Malignancy is the abnormal growth of cells or tissues that creates a cancerous tumor. These are some of the malignant entities responsible for the hyperechoic liver:

• Hepatocellular carcinoma, especially in a cirrhotic liver, is a common type of liver cancer.

• Cholangiocarcinoma or bile duct cancer

Benign lesions

A benign tumor has no significant effect on the body. However, below are some tumors to consider when the ultrasound reflects a positive image of a hyperechoic liver.

• Focal nodular hyperplasia or hepatic tumor that forms in the liver

• Hepatic hemangioma

The presence of hyperechogenicity may be due to fat around a liver lesion, but some non-fat lesions may also be echogenic.

What are the possible errors from imaging diagnosis?

A diagnostic error can harm an individual, with the average diagnostic error rates ranging from 3% to 5%. The four categories of errors that may occur from imaging tests include:

• An interpretive or cognitive error occurs when an abnormality is seen, but its significance and meaning are not correctly understood, resulting in an incorrect diagnosis

• Communication error, where the radiologist fails to communicate the results effectively

• Imaging or technique acquisition error, which can happen due to physical or technical limitations of the modality's imaging, like inadequate equipment, inexperienced staff, or staff shortage

• Perceptual errors, which can occur when abnormalities aren't detected due to under-reading, image manipulation, or a misleading patient history report

Radiologic interpretation is not a binary process — it takes far more techniques than the times used to acquire the images. Factors such as the volume of imaging studies, limited patient information, limited access to trained staff, and workplace distractions can constitute misinterpretations, resulting in misdiagnosis.

Additional diagnostic methods for liver disease

The doctor may request liver function tests for a specific diagnosis of liver disease. These tests help to diagnose and monitor liver damage or conditions by measuring hepatic proteins or enzymes in your blood.

Some tests show how well the liver is producing protein and clearing bilirubin, while other liver function tests measure enzymes released by the liver in response to damage or disease. 

Here are some examples of liver function tests:

• Prothrombin time (PT) is the time your blood takes to clot. Increased PT may indicate liver damage if you are not on blood-thinning medications like warfarin.

• High bilirubin levels during the bilirubin test might indicate liver disease or damage.

• Elevated levels of gamma-glutamyltransferase (GGT), an enzyme in the blood, may indicate bile duct or liver damage.

• L-lactate dehydrogenase (LD) is an enzyme in the liver that may indicate liver damage or other disorders if discovered in high amounts.

• Alanine transaminase (ALT) is an enzyme that helps to convert proteins into energy for liver cells. Its presence in the bloodstream may indicate liver damage.

• Aspartate transaminase (AST) is usually present in low levels, so increased levels may indicate liver or muscle damage.

• Alkaline phosphatase (ALP) is an important enzyme that breaks down protein. Higher levels may indicate liver disease or damage like a blocked bile duct.

The lowdown

The echogenic liver can reflect some conditions, such as fatty liver disease or cirrhosis. The anomalies present in the liver can either be malignant (cancerous) or benign (not harmful). Ultrasounds showing low echogenicity will appear as a dark image, known as hypoechoic. In contrast, images with high echogenicity will reflect bright light and are referred to as hyperechoic.

Most liver diseases are preventable through healthy lifestyle choices like reducing alcohol, avoiding smoking, being physically active, and losing weight. However, existing liver diseases are manageable through personalized treatment plans.

Frequently asked questions

What does echogenicity indicate?

Increased echogenicity is evidence of liver disease or damage. It may appear as white or bright light through an ultrasound to show a hyperechoic liver or a dull image to indicate a hypoechoic liver.

What is a diffusely echogenic liver?

A diffuse hyperechoic liver refers to the increased density of sound waves due to lesions, hepatic steatosis, cirrhosis, or chronic liver disease due to malignant or benign growth, which can cause hyperechoic liver.

What are echogenic foci in the liver?

Echogenic foci (multiple) or focus (singular) are bright spots in the liver reflected on the ultrasound. They are not necessarily liver disease or damage.