Hepatic steatosis (fatty liver) manifests on ultrasound as increased echogenicity of the liver parenchyma compared to the right renal cortex and spleen. As fat accumulates, the liver appears progressively brighter, sound penetration decreases, and the portal vein walls become less distinct. Fatty liver is graded as mild, moderate, or severe based on the degree of echogenicity, posterior attenuation, and vessel visibility. It is the most common liver finding on abdominal ultrasound and is associated with metabolic syndrome, obesity, alcohol use, and certain medications.