Starry sky hepatic ultrasonographic pattern in horses

The starry sky hepatic pattern is an unusual ultrasonographic appearance of equine liver characterized by numerous small, hyperechoic foci, some of which cast an acoustic shadow, distributed randomly throughout the hepatic parenchyma. Our objectives were to describe the signalment, clinical signs, clinicopathological findings, primary disease process, and ultrasonographic findings of horses with this ultrasonographic pattern, as well as determine the associated gross and histologic changes. The starry sky pattern was identified in 18 adult horses of mixed gender and breed. The horses had various clinical signs, with weight loss and anorexia reported most commonly. Liver size and parenchymal echogenicity were normal in most horses. The hyperechoic foci frequently caused acoustic shadowing. Biliary dilation was noted rarely. The ultrasonographic pattern was the result of numerous fibrosing hepatic granulomas in all horses evaluated histologically. γ-Glutamyltransferase was the most commonly elevated hepatic enzyme, though it was increased in fewer than half the horses. Fifteen horses had an additional disease that was identified as the apparent cause of clinical signs. Three horses had primary hepatic disease while 12 had diseases of other body systems. Therefore, the starry sky ultrasonographic pattern is likely incidental in most horses and not clinically significant. Improved recognition of this pattern and further investigation of affected horses may help refine the etiology and clinical significance of the granulomas.