Liver Cirrhosis With Portal Hypertension, Ascites & Splenomegaly Ultrasound Report Example | USG

Ultrasound Report:

Clinical History: Patient with known liver cirrhosis presents with increased abdominal girth, discomfort, and recent history of esophageal varices.

Findings:
Liver Size and EchoTexture: The liver demonstrates a reduced craniocaudal length of 9 cm, indicating a shrunken liver. The liver parenchyma is markedly coarse and heterogeneously echogenic, consistent with advanced fibrotic changes.

Surface and Margins: The liver surface is irregular and nodular. The liver margins are sharp, which is characteristic of significant fibrosis and cirrhosis.

Vasculature: The portal vein diameter is 0.7 cm, with signs of portal hypertension evident by the presence of collateral vessels and a slow portal vein flow.

Spleen: Splenomegaly is observed with a spleen length of 13 cm, suggesting portal hypertension and secondary hypersplenism.

Ascites: Moderate ascites is present, with free fluid noted in the peritoneal cavity, more pronounced in the perihepatic and pelvic areas.

Additional Findings: There are no identifiable focal liver lesions. The kidneys, gallbladder, and pancreas appear normal on ultrasound examination.

Impression: The ultrasound findings indicate a shrunken liver with severe cirrhotic changes, including a coarse and heterogeneously echogenic parenchyma, nodular surface, and sharp margins. The presence of moderate ascites, splenomegaly, and portal hypertension are consistent with advanced liver disease. These findings warrant further evaluation, including liver function tests and consideration for management of portal hypertension and its complications. Referral to a hepatologist and possible consideration for liver transplantation evaluation are recommended.