The ‘Disappearing’ Liver on CEUS: Nothing to Worry About

Case Presentation

A 72-year-old female patient was referred to our US department for contrast-enhanced ultrasound (CEUS) due to rectal cancer and focal liver lesions. In addition, she was suffering from chronic left heart failure (NYHA III) due to combined aortic valve disease and coronary heart disease. The patient’s liver was examined using a Hitachi Ascendus US machine in low MI mode. She received 2.4 ml of immediately prepared SonoVue^® (Bracco Imaging) intravenously, followed by 10 ml of saline solution. The known liver lesions were diagnosed as hemangiomas.

Starting about 150 seconds after the administration of SonoVue^®, hyperechoic spots emerged all over the liver, starting in the periportal regions ([Fig. 1]), subsequently growing together to form cloud-like “lesions” ([Fig. 2]). The visibility of the liver in grayscale decreased significantly and the liver parenchyma was not visible at all 3 min after the injection. The image was the same 1 h later. Changing from low to high MI mode did not improve the visibility of the liver parenchyma ([Fig 3]).

Fig. 1 Almost three minutes after the injection of SonoVue^®, hyperechoic scattered areas appeared close to the portal vein branches and start spreading. Left: low MI mode.

Fig. 2 Six minutes after the injection, the hyperechoic areas have become cloudy and the liver parenchyma is hardly visible on grayscale US.

Fig. 3 One hour after the injection, the regular structure of the liver parenchyma is completely invisible. Using the ‘high MI mode’ does not reduce the hyperechoic areas.

The patient was completely free of discomfort the entire time and her liver enzymes remained in the normal range. An ultrasound examination four weeks later depicted a regular liver parenchyma.