Abdominal Ultrasound Report
Patient Name: Sean Richards
Age/Sex: 45-year-old male
Referring Provider: Dr. Livia Green, MD – Hepatology
Indication: Known hepatitis C and cirrhosis; evaluation for ascites, hepatomegaly, and portal hypertension.
Technique:
Real-time grayscale and color Doppler ultrasound of the abdomen performed in multiple planes. Limited Doppler assessment of portal and hepatic veins was obtained.
Findings:
Liver:
Liver size is reduced with coarse, heterogeneous echotexture and irregular nodular contour, consistent with cirrhosis.
No focal hepatic mass identified.
Intrahepatic vasculature is patent but shows reversal of flow in the portal vein, consistent with portal hypertension.
Mildly increased echogenicity suggests fatty infiltration or fibrosis.
Gallbladder and Biliary Tree:
Gallbladder partially contracted; no gallstones or wall thickening.
Common bile duct measures 4 mm (within normal limits).
No intrahepatic biliary dilation observed.
Spleen:
Spleen enlarged, measuring 15.8 cm in length, consistent with splenomegaly secondary to portal hypertension.
Pancreas:
Partially obscured by bowel gas; visualized portions appear normal in echotexture and contour.
Kidneys:
Right kidney: 10.5 cm; left kidney: 10.8 cm.
Normal cortical echogenicity and thickness; no hydronephrosis or focal lesion.
Aorta/IVC:
Aorta of normal caliber.
Inferior vena cava patent and compressible.
Ascites:
Moderate free fluid visualized in Morrison’s pouch, perisplenic region, and pelvis, consistent with ascites.
Impression:
Cirrhotic liver morphology with coarse heterogeneous echotexture and nodular contour.
Reversal of portal vein flow indicating portal hypertension.
Splenomegaly (15.8 cm) consistent with portal hypertension.
Moderate ascites throughout the abdomen.
No focal hepatic mass or biliary obstruction identified.
Overall Impression:
Ultrasound findings are consistent with decompensated cirrhosis and portal hypertension, with associated ascites and splenomegaly. Recommend correlation with laboratory values, clinical findings, and continued monitoring of fluid balance.
Radiologist: Echo Fields, MD
Reviewed By: Dr. Livia Green, MD – Hepatology