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Contrast-enhanced ultrasound of the liver

Key sources
The following summarized guidelines for the evaluation and management of contrast-enhanced ultrasound of the liver are prepared by our editorial team based on guidelines from the European Federation of Societies for Ultrasound (EFSU 2020).


1.Diagnostic investigations

General indications
Obtain contrast-enhanced ultrasound in patients with inconclusive findings on CT or MRI.
Consider contrast-enhanced ultrasound as first-line contrast imaging modality in patients with renal insufficiency.
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  • Indications for detecting liver malignancies

  • Indications for characterizing focal liver lesions

  • Indications for characterizing focal liver lesions in liver cirrhosis

  • Indications for characterizing portal vein thrombosis

2.Diagnostic procedures

Indications for guiding biopsy
Attempt contrast-enhanced ultrasound guidance to biopsy focal liver lesions that are invisible or inconspicuous on B-mode imaging.
Consider contrast-enhanced ultrasound guidance for focal liver lesions with potential necrotic areas or if previous biopsy resulted in necrotic material.

3.Therapeutic procedures

Indications for intracavitary use
Consider intracavitary contrast-enhanced ultrasound for delineation of the liver abscess cavity and identification of correct drain position and of communication with other structures.
Consider intracavitary contrast-enhanced ultrasound to guide transhepatic biliary interventions.

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4.Perioperative care

Indications for intraoperative use
Consider contrast-enhanced intraoperative ultrasound to detect and characterize focal liver lesions not detected at preoperative imaging.
Obtain contrast-enhanced intraoperative ultrasound for assessment of the region for resection, where previously a pretreatment colorectal liver metastasis was present but has regressed.

5.Specific circumstances

Indications for use in pediatric patients
Obtain contrast-enhanced ultrasound for characterizing focal liver lesions in pediatric patients.
Obtain contrast-enhanced ultrasound follow-up of traumatic liver injuries in pediatric patients for the assessment of complications, reducing ionizing radiation exposure.

6.Follow-up and surveillance

Indications for monitoring treatment response: consider dynamic contrast-enhanced ultrasound for the quantitative assessment of response to targeted therapies in patients with malignant tumors of the liver.

7.Quality improvement

Technical considerations: ensure that the user of a contrast-enhanced ultrasound examination reports the type and dose(s) of contrast agent, the enhancement pattern and clinically relevant findings in a written format.
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  • Safety considerations