Contrast-enhanced ultrasound (CEUS) has been part of diagnostic imaging for more than three decades, evolving into a clinically established technique supported by international guidance from the European Society and Federation of Ultrasound in Medicine and Biology (EFSUMB). In the United Kingdom, CEUS is primarily associated with the characterisation of focal liver lesions (FLL), reflecting National Institute for Health and Care Excellence (NICE) recommendations for evaluating indeterminate liver findings. Applications beyond liver imaging include renal and testicular lesion assessment, interventional procedures and intracavitary use. Although CEUS continues to expand globally, its integration into routine UK clinical imaging remains limited, influenced by regulatory, financial, workforce and cultural factors affecting adoption across healthcare services.
Diagnostic Capability and Workflow Benefits
CEUS builds on established advantages of ultrasound, including real-time imaging, portability and the absence of ionising radiation. These characteristics enable bedside examinations, which may be particularly relevant in intensive care settings. The technique allows diagnostic imaging and interpretation within a single clinical encounter, with qualitative findings indicating that results are available the same day in approximately 80–90% of cases. Examination time is around 20–30 minutes, potentially shorter than magnetic resonance imaging (MRI), particularly when hepatocyte-specific contrast agents are involved.
Ultrasound contrast agents function as true blood pool agents, enabling continuous visualisation of enhancement phases rather than the discrete temporal sampling typical of computed tomography (CT) and MRI. CEUS is comparable to CT and MRI for characterising FLL, including distinguishing benign from malignant lesions and differentiating metastasis from hepatocellular carcinoma (HCC) in chronic liver disease, consistent with American College of Radiology (ACR) recommendations for HCC assessment. Higher spatial resolution compared with CT and MRI in this context is also described, supporting applications such as renal cystic lesion grading, evaluation of testicular lesions and use in interventional radiology.
Safety Profile and Economic Considerations
Ultrasound contrast agents have a well-established safety profile based on long-term clinical use. A dataset including 463,464 administered doses reports an adverse incidence rate of 0.034%, lower than that associated with iodinated contrast agents, with CEUS also being safe for paediatric patients. Safety considerations are accompanied by increasing attention to imaging pathway costs and efficiency.
Cost effectiveness is described particularly in the evaluation of incidental focal liver lesions. A cost analysis proposes potential annual savings of up to £2.2 million (€2.57 million) if CEUS is used as the first-line investigation following baseline ultrasound for FLL assessment. Establishing benign lesions earlier in the diagnostic pathway reduces repeat attendances and additional investigations aimed at excluding malignancy. CEUS also shortens diagnostic timelines, reducing steps in the patient pathway and helping manage demand for cross-sectional imaging. These operational benefits are relevant even when CEUS use remains limited to licensed indications, with ultrasound contrast agents also used outside radiology departments, including cardiology.
Structural and Cultural Barriers to Wider Adoption
Despite clinical and operational advantages, CEUS use in the UK is relatively limited compared with Europe, China and the United States. A 20-year bibliographic review places the UK seventh in publication output, with China and Italy producing the largest volume of work. Industry communication indicates SonoVue™ use in UK radiology departments is limited to around 60 accounts, compared with more than 200 in cardiology. In China, CEUS is estimated to be used in approximately 10–15% of ultrasound examinations.
Must Read: Expanding Role of Lung Ultrasound
Licensing and governance constraints are major structural barriers. Licensed indications are identified as breast, liver, cardiac and vascular imaging, with NICE approval in the UK limited to focal liver lesion characterisation. Expanding indications requires industry investment and regulatory approval, which may not be financially attractive. Off-label applications, including renal cyst assessment, are common but often face resistance from local regulatory boards. Financial pressures within the National Health Service (NHS) may also limit adoption, as contrast agents and enabling ultrasound software require initial investment and ongoing expenditure, often necessitating formal business cases.
Workforce and training considerations further influence adoption. CEUS is highly operator dependent, requiring both technical ultrasound skills and diagnostic expertise. Radiology training has increasingly focused on cross-sectional imaging, contributing to reduced ultrasound experience in some settings. Training opportunities may be limited by funding, regulatory approval requirements and time pressures. Practice is concentrated in university teaching hospitals, reducing access for patients and limiting opportunities to develop routine expertise. Early CEUS practice centred on focal liver lesion problem solving may also reduce case volume in individual departments, constraining training exposure.
Professional culture is another important factor. Growth in CT and MRI activity is exceeding growth in radiologist numbers, encouraging reliance on modalities that can be interpreted consistently and reported remotely. Ultrasound services in the UK are largely delivered by sonographers, while interest in CEUS is growing among hepatology, intensive care and emergency medicine clinicians. Some radiologists are reluctant to adopt ultrasound-based techniques because of time pressures, perceived complexity and concern about image quality. Clinical teams may default to CT and MRI requests because of limited awareness of CEUS capabilities, reinforcing existing imaging pathways. Establishing resilient CEUS services is challenging, as sustainable provision requires multiple trained operators rather than reliance on a single specialist.
Contrast-enhanced ultrasound is a safe and diagnostically effective imaging technique with potential to improve efficiency and reduce costs in selected clinical pathways, particularly in focal liver lesion evaluation. Real-time imaging capability, bedside accessibility and a low adverse event rate support its clinical value. Adoption within UK imaging services remains constrained by licensing limitations, financial considerations, training requirements, operator dependence and professional culture favouring cross-sectional imaging workflows. Addressing governance, workforce development and infrastructure needs may support broader integration of CEUS into clinical imaging practice.
Source: British Journal of Radiology
Image Credit: iStock
