ORIGINAL ARTICLE
Transient Segmental Enhancement of Pyogenic Liver Abscess:
A Comparison Between Contrast-Enhanced Ultrasound
and Computed Tomography
Kun Sun, MD,* Wei Zhu, MD,† Yan Luo, MS,‡ Yongzhong Li, MD,‡ and Xiang Zhou, MD§
Objective: This study aimed to investigate the correlation between the
transient segmental enhancement (TSE) of liver abscesses on contrast-
enhanced ultrasound (CEUS) imaging and contrast-enhanced computed to-
mography (CT) scans.
Methods: In total, 42 abscesses in 38 patients were evaluated with real-
time CEUS and contrast-enhanced CT imaging. The CT imaging and
CEUS examinations were performed within one to 2 days of each other
in all cases. The initial reports of the observations of TSE on CEUS scans
were correlated later with the findings of TSE on contrast-enhanced CT im-
ages. Contrast-enhanced CT was used as the reference standard to evaluate
the presence of TSE. Relationships between the 2 groups were analyzed
using the χ2 test. P < 0.05 was considered to be statistically significant.
Results: In 16 patients, 16 typical TSE signs were shown by CEUS.
Meanwhile, enhanced CT imaging showed 18 typical signs of TSE in
17 patients. We identified 38 patients with hepatic abscesses proven by
needle aspiration (10 patients) or image-guided biopsy (28 patients). Ten
patients had hepatobiliary cholelithiasis, 5 had diabetes mellitus type 2,
and 2 had gastric cancer, whereas no evidence of underlying hepatobiliary
or gastrointestinal diseases was found in the other 21 patients. Considering
that enhanced CT is the reference standard for the diagnosis of hepatic
abscesses, the sensitivity of CEUS in showing TSE was 89%, and the
specificity was 100%. The χ2 test indicated that CEUS and enhanced
CT were significantly correlated for detection of hepatic perfusion
disorders (P < 0.05).
Conclusions: The appearance of TSE in liver abscess was reliably
detected by CEUS, which correlated well with the enhanced CT
images (P < 0.05).
Key Words: contrast-enhanced ultrasound image, liver,
transient segmental enhancement
(J Comput Assist Tomogr 2017;00: 00–00)
P yogenic liver abscesses, caused by bacteria, result in localized
collection of pus and destruction of the surrounding hepatic
parenchyma.1 The epidemiology of pyogenic abscesses has
changed significantly in the modern era of antibiotic usage. The
clinical manifestations of pyogenic hepatic abscesses are highly
From the *Department of Ultrasound, Shenzhen Hospital, Southern Medical
University, Guangdong; †Echo Lab of Cardiology Department/Department of
Ultrasound, West China Hospital, Sichuan University; and ‡Department of Ultra-
sound, West China Hospital, Chengdu, Sichuan; and §Department of Ultra-
sound, National Cancer Center/Cancer Hospital, Chinese Academy of
Medical Sciences and Peking Union Medical College, Beijing, China.
Received for publication April 10, 2017; accepted June 5, 2017.
Correspondence to: Xiang Zhou, MD, Department of Ultrasound, National
Cancer Center/Cancer Hospital, Chinese Academy of Medical Sciences and
Peking Union Medical College, No. 17 Panjiayuan Nanli, Chaoyang
District, Beijing 100021, China (e‐mail: zhou.xiang@yeah.net).
K.S. and W.Z. contributed equally as joint first authors.
The authors declare no conflict of interest.
This work was supported by the National Natural Science Foundation of China
(NSFC grant 31170957) and the Sichuan Youth Science and Technology
Foundation (SYSTF grant 2012JQ0015).
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DOI: 10.1097/RCT.0000000000000659
J Comput Assist Tomogr • Volume 00, Number 00, Month 2017
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This paper can be cited using the date of access and the unique DOI number which can be found in the footnotes.
variable.1,2 However, a delayed diagnosis of hepatic abscess may
lead to higher mortality rates. The patient with hepatic abscess
usually has high fever. Therefore, the diagnostic accuracy is high
if the clinical features are combined with blood testing. However,
some cases of hepatic malignant tumors, especially those that have
large areas of necrosis, also may have fever and be misdiagnosed
as abscess. Therefore, it is important to use contrast-enhanced ul-
trasound (CEUS) for early diagnosis and initiate prompt therapy
to reduce morbidity and mortality.
The diagnosis of hepatic abscesses has been improved by
the use of ultrasonography and computed tomography (CT)
scans.2–4 Hepatic abscesses occasionally mimic the appear-
ances of other hepatic lesions such as metastases, in plain and
contrast-enhanced CT and ultrasound (US) images. It is important
to differentiate abscesses from other lesions in order to initiate ap-
propriate therapy. Several identifying features of hepatic abscesses
have been identified on CEUS and CT scans.2–9
Mathieu et al8 and Gabata et al10 reported that a transient seg-
mental wedge-shaped hepatic enhancement (TSE), which is asso-
ciated with hepatic abscesses, is sometimes visible in the early
phase of dynamic CT scanning and is of diagnostic value. The
purpose of this study was to investigate the correlation between
the presence of TSE due to liver abscesses on CEUS and
contrast-enhanced CT scans. Therefore, we retrospectively ana-
lyzed the CEUS and CT findings of TSE due to hepatic abscesses
in a cohort of patients from a single center.
The purpose of this study was to determine the sensitivity of
CEUS in detecting TSE by comparing the findings of helical CT
with the findings of CEUS and to conduct a pathologic analysis of
resected specimens.
MATERIALS AND METHODS
Patient Population
The study was approved by the research ethics board of West
China Hospital, Sichuan University, China. Informed consent was
obtained from all patients prior to enrollment in the study. Patients
with liver mass, fever, and inflammation as determined by periph-
eral hemogram were selected for this study between April 2010
and July 2014. Patients who had undergone liver CEUS examina-
tion and contrast-enhanced CT within 1 to 2 days before or after
the CEUS examination were included in the study. The patients
with more than 1 type of lesion, cardiac insufficiency, severe renal
dysfunction, hepatectomy, or splenectomy were excluded from the
study. The reasons for exclusion were patients with more than 1
type of lesion in the liver because the blood supply in some tumors
with abundant blood supply, such as hepatic hemangioma in addi-
tion to hepatocellular carcinoma, may affect the characteristics of
CEUS. We excluded patients with severe renal or cardiac dysfunc-
tion because of possible worsening of organ dysfunction by contrast
agent. We excluded patients with severe renal dysfunction because
of possible worsening of organ perfusion because of severe water
and sodium retention. Patients with cardiac insufficiency were
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Sun et al
excluded because cardiac insufficiency may influence microcircu-
lation perfusion. In this study, 1 patient with severe renal failure
and 2 patients with heart failure were excluded from the study. Pa-
tients who did not undergo both examinations and who were treated
with antibiotics for more than 3 days were also excluded from the
study. All patients were prospectively selected on the basis of detec-
tion of 1 or more hepatic abscesses, demonstrated by either CEUS
or CT.
We identified 38 patients with hepatic abscesses proven by
needle aspiration (10 patients) or imaged-guided biopsy (28 pa-
tients). Ten patients had hepatobiliary cholelithiasis, 5 had diabe-
tes mellitus type 2, and 2 patients had gastric cancer, whereas no
evidence of underlying hepatobiliary or gastrointestinal diseases
was found in the other 21 patients. There were 25 men and 13
women (male-to-female ratio 1.9:1.0) of median age 47 years
(range, 40–67 years).
Imaging Analysis
Computed tomography imaging and CEUS examination
were performed within 1 to 2 days of each other in all cases.
The CT and CEUS examinations were performed 1 or 2 days be-
fore the diagnosis of liver abscess, so the likelihood of a change in
the abscess before the clinical treatment was obtained was low. All
CEUS was performed by 1 diagnostic radiologist (X.Z.) who had
10 years of experience in US diagnosis and with knowledge of the
histological diagnosis of abscess by a biopsy or pus extraction
with hematoxylin-eosin staining or cytology and CT findings.
There were necrosis of liver tissue and pus in abscess cavities by
cytology report. Biopsy from abscesses showed abscess walls
formed by fibrous granulation tissue and hyperplasia by patho-
logic report. The examinations were interpreted by consensus of
2 radiologists (W.Z. and Y. Li) who were blinded to the CT and
histology results. The initial reports of the observations of TSE
on CEUS scans were correlated later with the findings of TSE
on contrast-enhanced CT scans. Contrast-enhanced CT was used
as the reference standard for evaluation of the presence of TSE
and to validate the findings on CEUS images.
Evaluation of Interreader Agreement
Digital CEUS cine clips or images stored on digital disks
were reviewed separately by 2 independent radiologists (W.Z.
and K.S., with 4 years of experience in CEUS, respectively) using
viewing software (Showcase [Trillium Technology, Ann Arbor,
Mich] and QLAB [Philips Healthcare, Bothell, Wash]). For each
lesion, 2 readers were asked to give a diagnostic score of TSE after
reviewing CEUS images. Each reader was trained for scoring TSE
and used a subjective 5-grade scale to identify diagnostic confi-
dence (grade 1 = TSE was definitely not present, grade 2 = proba-
bly not present, grade 3 = indeterminate likelihood of TSE, grade
4 = probably present, and grade 5 = definitely present). Two
readers individually reviewed the same CEUS images, and each
made his own TSE scores. The results of the reading were re-
corded on a data sheet, which included lesion number and size, in-
dependent diagnostic grade, and location with respect to liver
segment of TSE. Contrast-enhanced CT images of patients ob-
tained within 1 to 2 days before or after the CEUS examination
were obtained independently and retrospectively reviewed by a ra-
diologist (K.S. with 3 years of experience in CT image reading)
who was aware of the selection of focal liver lesion, CT diagnosis
of the lesions, and contrast-enhanced CT imaging features of TSE.
The same 5-grade scale for TSE diagnosis was used to grade diag-
nostic confidence in the presence of TSE. The location, number,
and scale of TSE diagnosis for every focal liver lesion detected
by using CT were recorded on a data sheet. For TSE diagnostic
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J Comput Assist Tomogr • Volume 00, Number 00, Month 2017
accuracy analysis of CEUS, grades 1 and 2 were defined as nega-
tive results, and grades 3, 4, and 5 were defined as positive results.
CEUS Examinations
All the ultrasonography studies were performed using a con-
vex probe (4 V1 vector transducer, 3–4 MHz; ACUSON Sequoia
512; Siemens, Mountain View, Calif) equipped with cadence con-
trast pulse sequencing (CPS) technology software. After activation
of the CPS-Mix mode with a low mechanical index (0.1–0.2) and ad-
aptation of image quality, a bolus injection of 2.4 mL of microbubble
SonoVue (Bracco Imaging BV, Geneva, Switzerland) was adminis-
tered intravenously, followed by 5 mL of 0.9% saline solution.7 A
3-way stopcock was used so that the saline flush could be admin-
istered immediately after the injection of contrast agent.
CT Examinations
Dynamic CT scans were performed using a 64-channel
multi–detector-row CT scanner (Brilliance 64-channel CT;
Philips Medical Systems, Cleveland, Ohio) and two 16-channel
CT scanners (Brilliance 16-channel CT [Philips Medical Systems]
and Siemens Sensation 16 [Siemens Co, Erlangen, Germany]).
Unenhanced and contrast-enhanced dynamic CT scans were ob-
tained. kVp of the x-ray tube was 100 to 120. Dynamic CT imag-
ing was initiated 30 seconds (early phase) and 90 seconds (late
phase) after the injection of Omnipaque 350 (GE Healthcare,
Nycomed Amersham, Princeton, NJ) contrast medium was initi-
ated. Subsequently, 100 mL of contrast medium was injected at
a rate of 3 mL/s with a power injector.11
Statistical Analysis
The statistical study was based on a single-lesion-per-patient
analysis. Statistical analyses were performed by using software
(SPSS version 10.1; SPSS, Chicago, Ill). For all tests, (P < 0.05)
was considered to indicate a statistically significant difference.
Weighted κ statistics were used to evaluate the hypothesis of con-
sistency between contrast-enhanced CT and CEUS. Agreement
was graded as poor (κ < 0.20), fair (κ = 0.20 to <0.40), moderate
(κ = 0.40 to <0.60), good (κ = 0.60 to <0.8), and very good
(κ = 0.80–1). The sensitivity, specificity, positive and negative pre-
dictive values, and accuracy for detection of TSE were calculated
based on the consensus of 2 CEUS readers.
RESULTS
Of 38 patients, 36 patients had solitary abscesses, and
2 patients had 3 abscesses each. Six patients underwent percutane-
ous drainage procedures of their abscesses and antibiotic treat-
ment. One patient underwent partial hepatic resection. The other
31 patients were treated conservatively with antibiotics.
CT Imaging Results
Dynamic CT imaging revealed 42 intrahepatic abscesses in
38 patients. Forty lesions (96%) were in the right hepatic lobe.
The mean size of the abscess was 5.5 cm (range, 1–10 cm).
Early-phase dynamic CT scans of 18 abscesses (43%) in
17 patients showed TSE surrounding the hepatic abscesses
(Figs. 1A and 2A). This transient hepatic enhancement occurred
only in the liver segments that involved the abscesses and was
not visible on late-phase dynamic CT (Figs. 1B, 2B, 3A, and 4A).
In 37 abscesses (88%), early- and late-phase dynamic CT images
showed central hypodense areas in the abscess; 34 of 42 abscesses
had irregularly enhancing septations (total or partial internal
honeycomb appearance) on both the early- and late-phase dynamic
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J Comput Assist Tomogr • Volume 00, Number 00, Month 2017 Segmental Enhancement of Pyogenic Liver Abscess

FIGURE 1. A representative image of a pathology-proven hepatic abscesses in a 43-year-old man. A, Early-phase (30-second) dynamic
contrast-enhanced CT scan shows the double-target sign, which consists of a central cystic area with an inner enhanced rim (arrow). Note
the wedge-shaped enhancement (arrowheads) of the hepatic parenchyma surrounding the mass. B, Late-phase (90-second) dynamic CT
scan shows thick rim enhancement (arrow). The wedge-shaped enhancement is no longer seen. C, In the early arterial phase (15 seconds),
the CPS scan with contrast-enhanced CT imaging shows a similar wedge-shaped enhancement area (arrowheads), thickened abscess wall
enhancement, and an internal liquefied cavity (arrow). D, During the late phase of US enhancement (50 seconds after injection), the
wedge-shaped enhancement observed in C has disappeared. E, This photomicrograph shows an organized abscess composed of
inflammatory cell infiltration and fibrosis. The portal tracts that surround the abscess have marked periportal inflammatory cell infiltration
and stenosis of the portal venules (hematoxylin-eosin staining, original magnification 40).

CT scans (Fig. 3A). Early- and late-phase dynamic CT scans
showed a relatively thick or irregular ring-like enhancement of
the intermediate and peripheral zones in 31 abscesses (74%;
Fig. 1A). In the late phase, hypodense areas were observed
around 7 lesions (17%; Fig. 3C).
Interreader Agreement
Interreader agreement for CEUS TSE interpretation based on
a 5-grade scale was good (κ = 0.721).
Sonography Results
Contrast-enhanced US revealed 38 intrahepatic abscesses in
38 patients, with a mean size of 5.3 cm (range, 1.5–11 cm).
In 16 (42%) of 38 abscesses in 16 patients, TSE was evident in
the early arterial phase of CEUS imaging, and it was located in the
segments that involved abscesses (Figs. 1C and 2C). With real-time
CEUS, the dynamic enhancement of abscess was characterized by
the rapid enhancement around the abscess during the arterial

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Sun et al J Comput Assist Tomogr • Volume 00, Number 00, Month 2017

FIGURE 2. Hepatic abscess in a 45-year-old man. A, This early-phase dynamic CT scan shows a huge right hepatic abscess with the
double-target sign (arrow) and a wide range of segmental enhancements that differ between the right and left hepatic lobes (arrowheads).
B, This late-phase (90-second) dynamic CT scan shows thick rim enhancement (arrow). The wedge-shaped enhancement is no longer seen.
The thickened abscess wall enhancement and double-target sign (arrow) become more obvious by this stage of the scanning process.
C, Contrast-enhanced US images with intercostal scanning in the early arterial phase. This CPS scan shows an internal liquefied cavity (arrow)
and segmental enhancement (arrowhead), which differ between the right and left hepatic lobes. D, Contrast-enhanced US images in the
late phase of US enhancement (50–55 seconds after injection of contrast agent) show that the wedge-shaped enhancement mentioned in
C has disappeared.

phase. This kind of imaging feature lasted until the late arterial phase.
In the 16 patients in whom TSE was demonstrated with CEUS, there
was no significant difference in the degree of enhancement of
lesions in the late phase (starting from the portal enhancement)
compared with the enhancement of the surrounding liver
parenchyma (Figs. 1D and 2D). The enhancement of 5 lesions in
5 patients even extended to the late phase when the enhancement
of local liver segment subsided at a significantly slower rate than
the surrounding liver. Liquefied lesions (35/38 abscesses [92.1%])
had an enhancing rim and a nonenhancing center. Consequently, a
clear internal margin was recognizable in these lesions (Figs. 2C,
3B, and 4B). The enhancing rim varied in thickness among
abscesses (Figs. 3B and 4B). The enhancement extended to the
internal septa and persisted during the later phases of CEUS
(Figs. 3 and 4). An overall internal honeycomb appearance of the
septa was identified by CEUS in 17 abscesses of a somewhat
smaller size (Figs. 2C and 3B). The local honeycomb-like
enhancement near the adjacent abscess walls was observed in 12
lesions. Perilesional hypoechogenicity of the abscesses was
noted in 3 abscesses in 3 patients between 1 and 3 minutes after
the injection of contrast (Fig. 3D). Three abscesses had high-
intensity internal echoes with reverberation of the signal.
Comparison Between Contrast-Enhanced CT
and Sonography
Of 38 patients, 16 (42.1%) showed typical signs of TSE.
Meanwhile, the images of enhanced CT showed characteristics
of typical TSE in 18 (47.4%) of 38 patients. There were 0 cases
scored to be indeterminate grade 3. These were classified as
non-TSE. Considering that enhanced CT was the reference stan-
dard for the identification of TSE, the sensitivity and specificity
of CEUS for identifying TSE were 89% and 100%, respectively.
The positive predictive value was 100%, and the negative predic-
tive value was 92%.
DISCUSSION
Low mechanical index sonography is a recently introduced
tool that allows real-time gray-scale exploration of the liver with
the administration of second-generation contrast media.1–3,10,12–16
Contrast-specific harmonic imaging techniques use a low applied
acoustic peak pressure to produce images that are based on the
nonlinear acoustic interaction between a US beam and
microbubbles in the contrast medium.12,17–19
Several enhanced CT and CEUS features of hepatic ab-
scesses have been reported in the literature.1–10,20 Hepatic

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J Comput Assist Tomogr • Volume 00, Number 00, Month 2017 Segmental Enhancement of Pyogenic Liver Abscess

FIGURE 3. Hepatic abscesses in a 48-year-old woman with a 6-year history of diabetes. A, Late-phase dynamic CT imaging shows a
relatively thick and irregular ring-like enhancement of the intermediate and internal honeycomb. B, Late-arterial-phase CPS scan shows a
central anechoic abscess cavity with irregularly enhancing septa (partial internal honeycomb appearance; arrowhead). C, A CT cross section
caudal to the section shown in A shows a broader range of the hypodense area. D, Contrast pulse sequencing angiographic images using
ultrasonographic scanning over the costal margin show that the adjacent section of the abscess in A to C has a wide area of perilesional
hypoechogenicity.

abscesses are depicted as single or multiloculated hypodense TSE that surrounded the hepatic abscesses identified by contrast-
masses that frequently have a peripheral rim or capsule that is en- enhanced CT images; in 16 of these 18 patients, TSE proved by
hanced clearly with both imaging modalities. Of the 38 patients in CT was identified by CEUS. Other researchers9 have hypothesized
our study, 18 patients had segmental or wedge-shaped hepatic that this transient enhancement is a result of localized hepatic

FIGURE 4. A, Late-phase (90-second) dynamic CT scan shows a thick rim (arrowheads) and septal enhancement (arrow). B, Late-phase (50- to
55-second) CPS image shows a thick rim (arrowheads) and septal enhancement (arrow).

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Sun et al
venous obstruction caused by the acute inflammation of the hepatic
parenchyma that surrounds the abscess. From findings on CT dur-
ing arterial portography and hepatic arteriography, Gabata et al10
hypothesized that a segmental or wedge-shaped enhancement re-
flects a decrease in blood flow in the portal venous system and a
compensatory increase in the rate of arterial blood flow. The dy-
namic enhancement of real-time CEUS, which includes the accu-
mulation of enhancement in the hepatic segment during the
arterial phase, may be explained by this hypothesis. Therefore, if
liver tumors resulted in portal vein thrombosis due to obstruction,
then the TSE sign would be evident in these patients and could aid
in the diagnosis of hepatocellular carcinoma or metastases.
It is important to differentiate hepatic abscesses from
arterioportal shunts due to tumors or other pathologies9,10 or from
tumors that are associated with TSE caused by portal or hepatic
vein stenosis or occlusion.12,13 Differentiation between multiple
abscesses and necrotic metastases is sometimes difficult, as they
both show enhancement of their rims. Segmental enhancement
of the hepatic parenchyma that surrounds the abscesses would
be a clue to the differentiation of these abscesses. In this study,
we conclude that CEUS is a useful modality for showing
segmental enhancement.
Two cases of TSE were not identified by CEUS. As these le-
sions were greater than 6 cm, the scope of the US scanner could
not display the entire lesion, making a valid comparison between
the 2 imaging modalities difficult. Altogether, CEUS is an effec-
tive and sensitive indicator of transient hepatic enhancement,
and the dynamic process means that the etiology of the signs
might be displayed more clearly by CEUS.
The so-called single- or double-target appearance of the rim
sign is considered to be one of the characteristic signs of hepatic
abscess in an enhanced CT image.8 Overall, 13 of the 42 abscesses
in our study had a double-target sign on dynamic CT scanning.
Mathieu et al8 surmised that the inner enhancing ring corresponds
to a capsule of the abscess, and the outer hypodense zone repre-
sents a localized zone of edema of the hepatic parenchyma that
surrounds the abscess.7 The double target and perilesional
hypoenhancing signs were far less typical when viewed by CEUS
than by enhanced CT. In the current study, only 3 lesions had
perilesional hypoenhancing areas in the late-phase view of CEUS,
but 13 lesions had them, as identified by CT. This might be attrib-
uted to several reasons: (1) compared with the scope of CT imag-
ing cross sections, the scanning and display areas of US were not
sufficient to show the typical target sign; (ii) because of low signal
intensity with low-energy US, it was found that the display of
microbubbles in the tissue microcirculation did not show paren-
chymal background, which means that it was difficult to distin-
guish the hepatic parenchymal details in CPS imaging; and (iii)
the inflammation around the abscess caused a faster washout rate
of the microbubble contrast agent than the normal liver tissue, thus
displaying hypoenhancing areas. There was no significant differ-
ence between CEUS and enhanced CT in the detection rates of ab-
scess walls and honeycomb-like enhancements.
This could be attributed to the following limitations of our
study: (a) less restriction with regard to the size of lesions, (b) a
lack of subanalysis of follow-up for patients treated with antibi-
otics, and (c) reference standard CT examinations performed by
a single reader, which makes the results more susceptible to errors
in image interpretation.
In summary, this comparison study of CEUS and contrast-
enhanced CT findings in pyogenic liver abscess showed that
CEUS can be used to identify the typical features of pyogenic
abscesses that correlate with the features found by the reference
standard investigation of contrast-enhanced CT images. The
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J Comput Assist Tomogr • Volume 00, Number 00, Month 2017
discovery of the TSE sign with CEUS could help to diagnose
liver abscesses in patients who have no significant fever or
changes in blood parameters or in those who present with
nonspecific sepsis.
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