Ultrasonography of cirrhosis

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Author: Mikael Häggström [notes 1]


Need of investigation

The diagnosis of cirrhosis can be made by physical examination and blood testing alone,[1] but ultrasonography is very helpful as an additional diagnostic tool at least in subtle disease.

Choice of modality

Ultrasonography is the first-line modality of medical imaging in patients with suspected cirrhosis and/or portal hypertension.[2] US is also typically the initial, first-line modality choice for the diagnosis and follow-up of portal hypertension.[3] For cirrhosis, it should be done without IV contrast.

How soon

In Swedish practice, ultrasonography for suspected cirrhosis should be done within 2 months.[notes 2]

In patients with known cirrhosis, surveillance ultrasonography of hepatocellular cancer (HCC) is indicated, generally every 6 months.[4]


Irregular liver surface and ascites.

Cirrhosis is indicated by:

  • Surface nodularity: (sensitivity 88%, specificity 82-95%)[5]
  • General coarse and heterogeneous texture[5]
  • Segmental hypertrophy or atrophy[5]
  • Relative expansion of the caudate lobe, creating a ratio of caudate width compared to right lobe width of >0.65 (sensitivity 43-84%, specificity 100%)[5]
  • Reduction of the transverse diameter (<30 mm) of the medial segment of the left lobe (segment IV).[5]
  • Fatty change which is variable [5]
  • Signs of portal hypertension[5]
  • Portal vein measurement and Doppler:
  • Dilated portal vein: >13 mm (sensitivity 42%, specificity 95-100%)[5]
  • Slow portal venous flow on Doppler: <15 cm/sec[5]
  • Reversal or alternating directions of portal venous flow[5]
  • Portal venous thrombosis
  • Cavernous transformation of the portal vein,[5] appearing like multiple veins.
  • Hepatic artery Doppler:
  • Increased velocity in hepatic artery[5]
  • Corkscrew appearance of hepatic arteries[5]
Doppler ultrasonography of the portal vein over 5 seconds, showing peaks of maximal velocity, as well as points of minimal velocity.
For further signs of portal hypertension, which may be used upon specific portal hypertension referral, see Ultrasonography of portal hypertension
  • Portal flow pulsatility: An increased portal vein pulsatility is an indicator of cirrhosis (even without portal hypertension), but may also be caused by an increased right atrial pressure.[6] Portal vein pulsatility can be quantified by pulsatility indices (PI), where an index above a certain cutoff indicates pathology:
Pulsatility indices (PI)
Index Calculation Cutoff
Average-based (Max - Min) / Average[6] 0.5[6]
Max-relative (Max - Min) / Max[7] 0.5[7][8] - 0.54[8]


In patients with a diagnosis of cirrhosis, surveillance ultrasonography of hepatocellular cancer (HCC) is indicated, generally every 6 months.[4]


  1. For a full list of contributors, see article history. Creators of images are attributed at the image description pages, seen by clicking on the images. See Radlines:Authorship for details.
  2. NU Hospital Group, Sweden


  1. Udell, JA; Wang, CS; Tinmouth, J; FitzGerald, JM; Ayas, NT; Simel, DL; Schulzer, M; Mak, E; et al. (Feb 22, 2012). "Does this patient with liver disease have cirrhosis? ". JAMA: The Journal of the American Medical Association 307 (8): 832–42. doi:10.1001/jama.2012.186. PMID 22357834. 
  2. Procopet, Bogdan; Berzigotti, Annalisa (2017). "Diagnosis of cirrhosis and portal hypertension: imaging, non-invasive markers of fibrosis and liver biopsy ". Gastroenterology Report 5 (2): 79–89. doi:10.1093/gastro/gox012. ISSN 2052-0034. 
  3. Bandali, Murad Feroz; Mirakhur, Anirudh; Lee, Edward Wolfgang; Ferris, Mollie Clarke; Sadler, David James; Gray, Robin Ritchie; Wong, Jason Kam (2017). "Portal hypertension: Imaging of portosystemic collateral pathways and associated image-guided therapy ". World Journal of Gastroenterology 23 (10): 1735. doi:10.3748/wjg.v23.i10.1735. ISSN 1007-9327. 
  4. 4.0 4.1 Fateen, Waleed; Ryder, Stephen (2017). "Screening for hepatocellular carcinoma: patient selection and perspectives ". Journal of Hepatocellular Carcinoma Volume 4: 71–79. doi:10.2147/JHC.S105777. ISSN 2253-5969. 
  5. 5.00 5.01 5.02 5.03 5.04 5.05 5.06 5.07 5.08 5.09 5.10 5.11 5.12 5.13 5.14 Dr Yuranga Weerakkody, A.Prof Frank Gaillard et al.. Cirrhosis. Radiopaedia. Retrieved on 2018-06-16.
  6. 6.0 6.1 6.2 Iranpour, Pooya; Lall, Chandana; Houshyar, Roozbeh; Helmy, Mohammad; Yang, Albert; Choi, Joon-Il; Ward, Garrett; Goodwin, Scott C (2016). "Altered Doppler flow patterns in cirrhosis patients: an overview ". Ultrasonography 35 (1): 3–12. doi:10.14366/usg.15020. ISSN 2288-5919. 
  7. 7.0 7.1 Goncalvesova, E.; Varga, I.; Tavacova, M.; Lesny, P. (2013). "Changes of portal vein flow in heart failure patients with liver congestion ". European Heart Journal 34 (suppl 1): P627–P627. doi:10.1093/eurheartj/eht307.P627. ISSN 0195-668X. 
  8. 8.0 8.1 Page 367 in: Henryk Dancygier (2009). Clinical Hepatology: Principles and Practice of Hepatobiliary Diseases . 1. Springer Science & Business Media. ISBN 9783540938422.