Grade 2 Fatty Liver Ultrasound Report Example | Diffuse Hepatic Steatosis Sonography | Abdominal USG

Ultrasound Report:

Clinical History:
Patient presents with elevated liver enzymes and reports fatigue and discomfort in the upper right quadrant of the abdomen. History of Type 2 Diabetes Mellitus and obesity. No history of alcohol abuse.

Findings:
The liver is enlarged with a craniocaudal length of 16 cm, which is above the normal range. The parenchyma exhibits diffuse increase in echogenicity suggestive of moderate fat infiltration, consistent with Grade 2 Hepatic Steatosis. There is no focal liver lesion identified. The intrahepatic vascular and biliary radicles are not dilated. The portal vein is normal in caliber. There is no evidence of ascites.
Vascular and Biliary Structures: No evidence of intrahepatic biliary dilation. Portal and hepatic veins appear normal in caliber and flow pattern.
Other Findings: No ascites is noted. The spleen, gallbladder, pancreas, and kidneys were visualized and appear normal without any significant abnormality.

Impression:
The ultrasound findings are consistent with Grade 2 Hepatic Steatosis (Fatty Liver). There is a diffuse increase in liver echogenicity and slight inhomogeneity in liver texture, with a liver size of 16 cm, suggesting moderate fatty infiltration. No additional focal liver lesions or signs of advanced liver disease are identified. Clinical correlation and further evaluation may be warranted based on the patient's clinical history and risk factors.

Recommendations:
- Consideration for lifestyle changes including diet modification and exercise to reduce liver fat content.
- Further evaluation with liver function tests and potential fibroscan to assess for any fibrosis.
- Regular monitoring of liver size and texture with follow-up ultrasound in 6-12 months or as clinically indicated.

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