Intended for healthcare professionals

Practice Rational Imaging

Investigating focal liver lesions

BMJ 2012; 344 doi: (Published 08 February 2012) Cite this as: BMJ 2012;344:e657
  1. Dhruv V Patel, specialist registrar, clinical radiology,
  2. Victoria Scott, foundation year 2 doctor,
  3. James Pilcher, consultant radiologist
  1. 1St George’s Healthcare NHS Trust, London, SW17 0QT
  1. Correspondence to: D Patel dhruv_patel{at}

The authors discuss the commoner focal liver lesions encountered and the methods available for further investigation

Learning points

  • Incidental liver lesions on medical imaging are relatively common and the vast majority are benign

  • Fatty infiltration is increasing in prevalence and can make the detection and characterisation of focal liver lesions difficult

  • The choice of and need for further investigation when a focal liver lesion is identified depends on several patient factors and ideally should be recommended by the reporting radiologist

  • Contrast enhanced ultrasonography, computed tomography, and magnetic resonance imaging of focal liver lesions rely on the recognition of characteristic enhancement patterns

  • Biopsy may be needed where imaging fails to characterise a lesion adequately

A 31 year old Anglo-Indian man presented to his general practitioner for a discussion of cardiovascular risk factors because of a strong family history of ischaemic heart disease. He had no medical history of note. The patient denied excessive consumption of alcohol, although he admitted to a relatively unhealthy, high fat diet. Routine liver function tests showed raised alanine aminotransferase and aspartate aminotransferase. The patient was subsequently referred for abdominal ultrasonography, which showed moderate fatty change throughout the liver and an incidental 2.4 cm focal mass of mixed reflectivity in segment VII (fig 1).

Fig 1 Conventional ultrasound image showing focal hyporeflective lesion (white arrow) in segment VII of the liver with background increased reflectivity consistent with fatty infiltration

What is the next investigation?

Various imaging methods incidentally show focal liver lesions. The primary function of investigating a focal liver lesion is to characterise it with confidence as either needing no or only routine follow-up, or needing further, more rigorous exploration (including biopsy). The exclusion of malignancy is paramount, and most benign lesions can be characterised on non-invasive imaging grounds alone.

Conventional ultrasonography is often used as the first line imaging investigation …

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