Focal liver lesions: cyst, haemangioma, abscess and tumour
- Finding
Most spots found in the liver are harmless cysts or haemangiomas; the patient's history and the contrast pattern sort out the rest.
What it is
A focal liver lesion is a spot that looks different from the normal liver on ultrasound, CT or MRI. Many are found by chance. The question that matters most is the setting: in a healthy adult with no cancer and no liver disease, most small lesions are simple cysts or haemangiomas. In cirrhosis, a new solid nodule is hepatocellular carcinoma until proved otherwise. In a patient with a known cancer, multiple lesions are usually metastases, which are the commonest malignant tumours of the liver. Fever and pain point to an abscess. Ultrasound finds and separates cystic from solid lesions; multiphase contrast CT or MRI (arterial, portal venous and delayed phases) characterises solid ones by how they take up and release contrast. Many lesions can be named without a biopsy, and a haemangioma should not be biopsied because it can bleed.
What it looks like
- Simple cyst: anechoic, thin-walled, with posterior acoustic enhancement on ultrasound; water density without enhancement on CT.
- Haemangioma: well-defined and bright (hyperechoic) on ultrasound; on CT or MRI, peripheral nodular, discontinuous enhancement that fills in towards the centre over time.
- Haemangioma on MRI: very bright on T2-weighted images, similar to fluid.
- Pyogenic abscess: a low-density lesion with an enhancing rim and surrounding oedema, often several clustered together; sometimes gas.
- Amoebic abscess: usually single, in the right lobe near the liver capsule, in a patient from or returning from an endemic area.
- Hepatocellular carcinoma in cirrhosis: arterial-phase hyperenhancement with washout in the portal venous or delayed phase, often with a capsule.
- Metastases: usually multiple; colorectal ones are best seen in the portal venous phase; some (neuroendocrine, renal, melanoma, thyroid) enhance in the arterial phase; on ultrasound a target appearance.
Why it looks that way
- Fluid lets sound through, so a cyst is black with brighter tissue behind it; it has no blood supply, so it never enhances.
- A haemangioma is a sponge of slow-flowing vascular spaces, so contrast enters at the edge and pools slowly towards the middle.
- Hepatocellular carcinoma is fed by the hepatic artery rather than the portal vein, so it lights up early and then looks darker than the liver.
- An abscess has a liquefied centre that does not enhance and an inflamed, vascular wall that does.
| Lesion | Ultrasound | Contrast CT or MRI | Setting |
|---|---|---|---|
| Simple cyst | Anechoic, posterior enhancement | Water density, no enhancement | Any age, common |
| Haemangioma | Well-defined, bright | Peripheral nodular, fills in to the centre | Commonest benign solid lesion |
| Pyogenic abscess | Complex, fluid with debris | Rim enhancement, clusters, sometimes gas | Fever, biliary disease |
| Amoebic abscess | Round, low-level echoes | Single, peripheral, right lobe | Endemic area |
| Hepatocellular carcinoma | Solid nodule in a cirrhotic liver | Arterial enhancement, then washout | Cirrhosis, hepatitis B |
| Metastases | Multiple, target appearance | Mostly portal venous; some arterial | Known primary cancer |
Differential and pitfalls
- Ask about cancer, cirrhosis or chronic hepatitis B, fever, travel and oral contraceptive use before interpreting a liver lesion.
- A complex cyst (septa, nodules, thick wall) is not a simple cyst and needs further imaging.
- Do not biopsy a suspected haemangioma; the typical enhancement pattern is enough.
- In cirrhosis, hepatocellular carcinoma can be diagnosed on typical multiphase imaging without a biopsy; look for tumour thrombus in the portal vein.
- Focal nodular hyperplasia and hepatic adenoma are other benign solid lesions in young women; adenoma can bleed and needs specialist follow-up.
Next step
- Typical simple cyst or haemangioma in a patient without cancer or liver disease: usually no further imaging.
- Indeterminate solid lesion: multiphase contrast CT or liver MRI, reviewed with the radiologist.
- Cirrhosis with a new nodule: multiphase CT or MRI and referral to hepatology; check alpha-fetoprotein; cirrhosis also needs ultrasound surveillance about every six months.
- Suspected abscess: blood cultures and amoebic serology, start treatment and ask interventional radiology about drainage of a large or pyogenic abscess.
- Lesions in a patient with known cancer: staging CT and referral to oncology; biopsy only if it changes management.
Test yourself
Think of the answer, then tap the question to see it.
What is the typical enhancement pattern of a hepatic haemangioma?
Peripheral, nodular, discontinuous enhancement in the arterial phase that gradually fills in towards the centre on later phases.
Which multiphase pattern is typical of hepatocellular carcinoma in cirrhosis?
Arterial-phase hyperenhancement followed by washout in the portal venous or delayed phase, often with an enhancing capsule.
Why should a suspected haemangioma not be biopsied?
It is a vascular lesion that can bleed, and its imaging pattern is usually diagnostic, so a biopsy adds risk without benefit.
What features favour an amoebic over a pyogenic liver abscess?
A single lesion in the right lobe near the capsule in a patient from an endemic area; pyogenic abscesses are more often multiple and clustered.
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Educational content; it does not replace a radiologist's report and is not a clinical instruction. Each study is ordered on the patient's assessment and your institution's protocols.
Sources: Cavernous Hepatic Hemangioma (StatPearls (NCBI Bookshelf), 2022); Liver Abscess (StatPearls (NCBI Bookshelf), 2023); Hepatocellular Carcinoma (StatPearls (NCBI Bookshelf), 2023); Liver Metastasis (StatPearls (NCBI Bookshelf), 2023).
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Representative model, for educational purposes only.