Help with my ultrasound result

I am 42 years old. I have been diagnosed with Chronic HBV 20 years ago, and have been proactively monitoring the condition with blood tests and Ultrasound. Most of the time the results were good and virus load undetected. About 3 years ago, the virus load started to fluctuate between 400-2000, and my doctor decided to use Entecavir. The medicine works quite well on me, my virus load becomes undetected in 3 months after taking it.

About 6 months ago, in a routine ultrasound test, a 6mmx6mmx4mmm lesion was discovered, and I followed up with AFP and CT scan. The AFP value was 2, within the normal range; and the CT scan couldn’t find that lesion as it was too small. 3 months later, I did another Ultrasound test to monitor the lesion. I got the results yesterday. The result is as below:

"Stable appearance of the very subtle ovoid, heterogenous and slightly hyperechoic lesion within segment 3. It measures 6x7x4mm. No internal vascularity was appreciated. Further assessment is difficult due to adjacent cardiac motion. "

The conclusion is that the lesion is indeterminate. so basically in 3 months time, it grew by 1mm. I will go back to see my specialist next week. I am a bit worried, as I do feel some discomfort under the rib, although I have had this feeling for many years now. I hope this is a benign lesion, but the lesion is heterogenous, making me worried. “No internal vascularity”, is this a good thing? Can someone help to interpret the result? Since CT couldn’t detect this lesion, should I ask to get a MRI?
A very worried middle-age man

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Hi Civilke,

I’m in the same boat as you, I’m 41 and have chronic hbv but I’ve had it since birth. I’m currently taking Vemlidy with no detectable viral load. I’ve also felt discomfort under my rib for the past 3 years but have always been told it’s my stomach and not my liver causing the pain. It comes and goes and doesn’t cause me any real pain. (1 on a scale of 1-10) but it is concerning given my HBV.

I also had a worrisome ultrasound late 2020 that showed a liver with “slighly coarse and heterogeneous hepatic echotexture” and a lesion that measured 1.9x 1.2 x 2cm. I got an MRI and they could not find the lesion seen on ultrasound and considered it “artifactual”. I think there was mention of some simple cysts but that’s about it. I was more concerned by the finding of a small hiatal hernia more than my liver! it explained my occasional GERD. It’s been 6 months since the MRi and I just got my followup ultrasound done last week and am waiting on the results. The radiologist hasn’t signed it out yet but my doctor has already seen it and thinks it looks fine.

I can certainly empathize with your situation and hope my story helps to alleviate your anxiety. Try not to worry (I know easier said than done!) and keep getting those followup ultrasounds!

Best regards,

Rebecca

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Hi @Civilke,

I will let one of the @HealthExperts interpret your results, as I am not a medical professional. I might say that the majority of liver nodules that are found by US are benign and most people who have them would never know unless they were scanned (this is discussed in a similar thread here: Discovery of a liver nodule).

Also, I would not be too concerned with the difference in size between the two measurements. The difference of 1mm could be due to differences in the radiographer measuring the nodule, particularly since they mention that it is very subtle.

Hope this helps,
Thomas

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Hi Civilke,

It is difficult to really comment on an ultrasound as the precise measurements can vary, as can the appearance of lesions.

Typically CT scan or MRI if available are needed for a definitive answer and these may need to be repeated along the way.

It can be complicated, so best to follow your specialist’s advice on this. I agree there is no need to get anxious as this stage, but you should definitely see your specialist who can look at the scan and decide what else to do.

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There was probably no need to start ETV as anti-HBV therapy is not based only on HBV DNA levels. As far as the liver focal lesion is concerned, would suggest MRI. I guess there is no evidence of cirrhosis, correct ? how is fibroscan ? viral genotype ? ethnicity ?

Prof. Pietro Lampertico, MD, PhD

Full Professor of Gastroenterology

Head of Gastroenterology and Hepatology Division

Fondazione IRCCS Ca’ Granda Ospedale Maggiore Policlinico

University of Milan

Via Francesco Sforza 35

20122- Milan

Italy

Phone +390255035432

Fax +390250320410

Email pietro.lampertico@unimi.it

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Rebecca, thank you for sharing your experience with me. It definitely alleviates my anxiety. The discomfort feeling under the rib is very similar to mine. It comes and goes, probably on scale 1 as well. I have seen different doctors over years and tried to figure out the reason or if it is related to HBV. Most doctors told me it is in my head, and think not related to HBV. It is quite frustrated, cos I know it is there, not my imagination. Particularly if I don’t sleep well, then it can be quite bad. Well, this discomfort feeling has been with me for more than 10 years, I try to live with it and accept this is part of me. However, since this lesion was discovered, I restart to worry about this discomfort feeling. Thank you again, and I feel much better today, and will practice to stop worrying. Please let us know how you go with your follow-up result.

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Thank you Prof. Lampertico for your response. I will ask my specialist see if she is happy to let me do a MRI. From the untrasound and CT scan results, there is no evidence of cirrhosis. For Fibroscan, the last time I did it was nearly 10 years ago now, at that time was 4.5kpa. I will ask to get a fibroscan done this time. I am Chinese. I haven’t done a viral genotype test, so I don’t know. Should I ask my doctor to do a genotype test?

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Thank you Thomas for inviting experts to come and review my result. I am so overwhelmed, people here are so kind to offer help and provide comforting. I was quite frustrated when the Chinese HBV community forum becoming not accessible, so good to find a new home.

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Thank you Mark. I will try to stop being anxious. Repeating CT or MRI in the future definitely sounds like a good strategy. I got so many ideas here for the discussion with my doctor next week.

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You cannot ask for viral genotype now as you are on ETV therapy but the fact that you are Chinese is enough

Prof. Pietro Lampertico, MD, PhD

Full Professor of Gastroenterology

Head of Gastroenterology and Hepatology Division

Fondazione IRCCS Ca’ Granda Ospedale Maggiore Policlinico

University of Milan

Via Francesco Sforza 35

20122- Milan

Italy

Phone +390255035432

Fax +390250320410

Email pietro.lampertico@unimi.it

signature.jpg

I got my ultrasound back today and it looked good! I had some sign of inflammation because I recently took an antibiotic that caused my liver enzymes to flare up but they are slowly coming back down. I’m retesting weekly to keep an eye on them but am optimistic that they will recover with time.

Thanks for caring!

Rebecca

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Hi, Civilke,
the result of Ultrasound is always not accurate and is strongly affected by operator- and patient-dependent factors.
What you said the lesion is too small. MRI with Gd-EOB-DTPA is much more accurate than enhanced CT and conventional contrast-enhanced MRI in diagnosing small liver lesions. MRI with Gd-EOB-DTPA has the diagnostic capability for small HCC with a diameter of ≤ 2 cm.
You need to follow your specialist’s advice. If you still worried and anxious about it. you can think about the method.

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Than you for your advice, Yuan! I will mention the MRI method you mentioned to my specialist next week. Hope she can get on board.

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Hey Rebecca, good to hear your ultrasound was good result.your last MRI result suggested the lesion can be artifactual. Does that imply that lesion might not existing, but a wrong interpretation by the operator? Does your current ultrasound see the same lesion again? Mine is probably not artifactual, as the latest ultrasound has identified the lesion on the same spot. I have felt much less anxious now, after receiving so much supports and suggestions here, at least I know what I can talk to the specialist in my next appointment.

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On my current ultrasound, the radiologist said there were no visualized hepatomas, so it is in line with my MRI results from December which did not find the 2cm lesion seen on my previous ultrasound. It is my understanding that an artifact is an imaging error, so it doesn’t accurately reflect my actual anatomy. It can be caused by many things which are way too complicated for me to understand! I didn’t even know this could happen so it has certainly been an eye-opening experience. But even when I thought I had a nodule, my doctor said coupled with the size, my labs, fibroscan, afp levels and other health markers, he assumed it was a benign lesion from the start. Hopefully it’s the same for you! But yes, please talk to your doctor and let him know your concerns. Having open, honest conversations with my doctor has really been helpful in controlling my anxiety this past year! I think he’s starting to understand my personality and knows I’m not a passive patient who is content to do what he says without question! :0)

All my best,

Rebecca

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HI Civilke,

I just wanted to followup with you since I just met with my hepatologist today and asked him why so many HBV patients experienced pain under the right rib. He said that he does not think it is from the liver but from pressure on a nerve that wraps from the spine to the ribs surrounding the liver. He doesn’t know why the pain is usually felt under the right rib since the nerve expands beyond this area. He says he mostly hears this complaint from his patients with fatty liver disease and has had only 2 patients opt to have an injection that blocked the nerve, which got rid of the pain. He said most people are like you and me, and only find the pain to be an annoyance and not worth being treated. He said it was nothing to worry about unless the pain started to effect daily living. I tried to do more research on the condition he described and I think it is called Intercostal neuralgia. I’m no doctor and may have misinterpreted what he said so take this with a grain of salt! It’s hard to absorb all the information doctors throw at you in the short period of time you have with them. But it was nice to get a more in depth explanation besides don’t worry about it, it’s all in your head!

Rebecca

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hi Rebecca, Thank you for the update and information. During my last consultation, my specialist has also reassured me that the pain is not caused by my liver. She said normally the pain in this area is caused by gallbladder, but my gallbladder is fine. She can’t suggest any solution. I am actually seeing a physiotherapist right now, and he is giving me some exercise to do. I have been doing this for 2 weeks now. I can feel some improvement, but I am not sure maybe I am just feeling ok these 2 weeks. I will keep visiting him for a period of time, I will let you know if there is any fundamental change to my situation.

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Let me know with progress, as even I do face same right rib pain. Under ribs and it is not from deep inside it is upper pain like coming from bones. Infact I don’t call it pain I call it discomfort at some position. Sometimes it is 0 and sometimes it is 1 or 2 out of 10