We are doing a VExUS scan in a patient with known cirrhosis and possibly concurrent alcoholic hepatitis. In the left upper quadrant, you see a large spleen (which is not unexpected in cirrhosis) but what’s above that?

Let’s see another image. Two differentials that come to mind are left lung base consolidation and hemothorax with clotted blood (especially if the patient underwent thoracentesis recently) or a peri-splenic hematoma.

The surface of the structure is too homogeneous for a consolidation, which typically contains air bronchograms. Then is it clotted blood? No, because color Doppler demonstrates blood flow.

It is actually enlarged liver spreading over the spleen. Below image is a sweep from the left upper quadrant going to the right showing continuity with the liver. Labeled version of figure 1 and CT correlation included. Because our patient had hyperechoic liver, it was relatively easier to identify it as a distinct structure. Otherwise, it can be difficult if you don’t sweep through and demonstrate connection with the liver.

In this context, it’s good to know about an anatomic variant of the liver called ‘Beaver tail liver’. It is a term used to denote elongated left lobe of the liver wrapping around the spleen as shown below. Very similar to our case except that ours is pathologic hepatomegaly.