Liver lacerations on ultrasound

Written by: Sabrina Rosengarten

Edited by: Joann Hsu

72 yo M undomiciled with unknown PMHx presented as a trauma delta. He was found by EMS on the ground after he “fell and hit his head” while walking along the highway. AOx1-2. Complains of right sided hip pain. He was found to have a RT femur fracture, RT posterior ribs 7-10 fractured, RT anterior 2-7 ribs fractured, a large pneumothorax on the right, SAH, right wrist fracture and left thumb fracture.


eFAST was not performed, however in the RUQ we saw:

For comparison, here is a normal liver in the RUQ view:

CT showed a “5.9 x 2.7 cm serpiginous laceration or hematoma primarily within segment 4 of the liver. Scattered subcentimeter hypodensities which are too small to characterize.”

Liver ultrasound

During a FAST exam (focused assessment with sonography in trauma) the main goal is to find free fluid, with the most critical spots in the right upper quadrant (RUQ) being Morisson’s pouch, the caudal liver edge, and the space between the diaphragm and the liver. However, solid organs, such as the liver, can be further assessed for abnormalities in their contours or for heterogeneity of their parenchyma. These are often hard to see, however if you are able to see hypoechoic regions in the liver, you can put color doppler on. If there is no flow it’s likely a laceration or hematoma in the setting of trauma (1). Look in the areas close to the ligaments, as these are the most likely areas for a laceration to occur in blunt trauma.

Why is this important? 

Severe lesions of the liver, even without free fluid, will require the OR. If a patient is too unstable to make it to CT scan, we can help surgeons decide which organs to prioritize intervention in first. Additionally, if you see a laceration, but no free fluid, you should repeat a FAST exam after a period of time to ensure that fluid has not accumulated. Remember that you need about a coke can’s worth of fluid for a FAST to even be positive. Also, 80% of the time hepatic lacerations are associated with other abdominal injuries, so it would raise your index of suspicion for other concerning intraabdominal damage (2).



US Approach

Traditionally we start with the RUQ in blunt trauma. Start with either the phased array or curvilinear probe, probe marker pointing towards the patient’s head in the sagittal position, along the mid-axillary line at approximately the 10th intercostal space. Make sure to obtain the critical areas including the caudal tip, Morrison’s pouch, and hepato-diaphragmatic space, searching for fluid (hypoechoic). You may need to angle the probe to fit between the ribs or slide up or down a rib space. Trendelenburg positioning can also help to accumulate any fluid. To identify liver lacerations, also search within the liver parenchyma for more hypo- or hyperechoic areas that do not have flow on color. Hypoechoic areas tend to be more acute, while subacute/chronic blood tends to be hyperechoic since as blood clots it becomes more complex and dense, sometimes with septations and internal echoes from debris. This is also harder to differentiate from normal tissue (3,4).  



Below are some images, courtesy of ultrasoundcases.info, to help familiarize you with lacerations and hematomas. Hematomas can be intraparenchymal or subcapsular and tend to be more homogeneous. Lacerations are more stellate.  


Innovations in Ultrasound for the future

Ultrasound for evaluation of solid organ injury is very variable in sensitivity and is not currently a reliable study (6). However, recent research has looked at pairing ultrasound with IV contrast to better highlight solid organ injury. The contrast used consists of microbubbles, which are bubbles of gas smaller than RBCs. They produce high frequency echoes that increase the echogenicity of the tissue that they are in. There is some interesting research on how these microbubbles can be used in procedures, such as thrombolysis, detecting atherosclerotic plaques, and targeting specific tissues (7). This has the benefit of avoiding ionizing radiation, which is particularly appealing in pediatrics, and in patients who require serial imaging. One study found that the sensitivity approaches that of CT, although it is operator dependent (8). Another meta-analysis found it significantly more sensitive and specific than the standard FAST for abdominal injuries, especially solid organ injury (9). With training and re-education, it has real promise as a definitive imaging modality.   



  1. Ramaswami, A., Sinha, T. P., (2022). POCUS in Abdominal Trauma: Old Gadget, New Insights. Abdominal Trauma - New Solutions to Old Problems. https://doi.org/10.5772/INTECHOPEN.107049

  2. Liver trauma | Radiology Reference Article | Radiopaedia.org. (n.d.). Retrieved October 28, 2023, from https://radiopaedia.org/articles/liver-trauma?lang=us

  3. FAST | Sonoguide. (n.d.). Retrieved October 28, 2023, from https://www.acep.org/sonoguide/basic/fast

  4. Dinh, V. eFAST Ultrasound Exam Made Easy. (n.d.). Retrieved October 28, 2023, from https://www.pocus101.com/efast-ultrasound-exam-made-easy-step-by-step-guide/#Recommended_eFAST_Exam_Sequence

  5. Liver Segments Schematic (diagram). Retrieved October 28, 2023, from ultrasoundpaedia.com.

  6. Kendall, J. L., Faragher, J., Hewitt, G. J., Burcham, G., & Haukoos, J. S. (2009). Emergency Department Ultrasound Is not a Sensitive Detector of solid Organ Injury. Western Journal of Emergency Medicine, 1(1). www.westjem.org

  7. Ajmal, S. (2021). Contrast-Enhanced Ultrasonography: Review and Applications. Cureus, 13(9), e18243. https://doi.org/10.7759/CUREUS.18243

  8. Miele, V., Piccolo, C. L., Galluzzo, M., Ianniello, S., Sessa, B., & Trinci, M. (2016). Contrast-enhanced ultrasound (CEUS) in blunt abdominal trauma. EMERGENCY RADIOLOGY SPECIAL FEATURE, 89. https://doi.org/10.1259/bjr.20150823

  9. Sutarjono, B., Kessel, M., Alexander, D., & Grewal, E. (2023). Is it time to re-think FAST? A systematic review and meta-analysis of Contrast-Enhanced Ultrasound (CEUS) and conventional ultrasound for initial assessment of abdominal trauma. BMC Emergency Medicine, 23(1), 1–14. https://doi.org/10.1186/s12873-023-00771-4

  10. 1.1.14 Liver Trauma | Ultrasound Cases. (n.d.). Retrieved October 28, 2023, from https://www.ultrasoundcases.info/cases/abdomen-and-retroperitoneum/liver/liver-trauma/

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