Diagnosis

Liver injury

Etiology

Cause [ums]

• Trauma:

  • Blunt 91% (57% traffic accidents)

  • Penetrating

• Iatrogenic

Pathophysiology [ums]

1. Blunt injury: Locally fixed under the diaphragm --> susceptible to shear forces from deceleration injuries

2. Penetrating injury: anterior location and relative large size (gunshot or stab wounds)

3. Highly vascular parenchyma with thin-walled vessels and high blood flow

American Association for the Surgery of Trauma Liver injury classification:

1. Grade 1: minor injuries represent 80-90% of all injuries, require observation

   • Hematoma: Subcapsular, non-expanding, <10% of surface area

   • Laceration: Capsular tear, non-bleeding, <1 cm parenchymal depth

2. Grade 2:

   • Hematoma: Subcapsular, non-expanding, 10-50% of surface area

     or intraparenchymal non-expanding, less than 2 cm in diameter

   • Laceration: Capsular tear, active bleeding, 1-3 cm parenchymal depth, <10cm in length

3. Grade 3:

   • Hematoma: Subcapsular, >50% of surface area or expanding, ruptured subcapsular hematoma with active bleeding, intraparenchymal hematoma >2 cm

   • Laceration: Capsular tear >3 cm parenchymal depth

4. Grade 4:

   • Hematoma: Ruptured intraparenchymal hematoma with active bleeding

   • Laceration:  Parenchymal rupture with bleeding involving 25-50% of the lobe

5. Grade 5:

   • Laceration:  Parenchymal rupture with bleeding involving >50% of the lobe

   • Vascular: Juxtahepatic venous injuries (retrohepatic vena cava/hepatic veins)

6. Grade 6: Hepatic avulsion

Complications [ums]

• Liver abscess

• Bile leak/fistula

• Hemobilia

• Bilihemia

• Bile duct stricture

• Liver necrosis

• Liver failure

Epidemiology

Incidence per 100.000 [ums][8eq][ypa]

Approach

• Ultrasound abdomen

• CT abdomen (if hemodynamic stable patient)

• Diagnostic celiac angiography

Treatment

Treatment strategy: [8eq][ums]

1. Nonoperative management: hemodynamic stable, no active bleeding

2. Therapeutic transcatheter arterial embolism: Grade 1-3 injury and fluid demand <2L/h

3. Surgery: If hemodynamic unstable patient

   • Perihepatic packing

   • Mesh rapping

   • Resection debridement

   • Anatomical resection

   • Complete vascular isolation with veno-venous bypass and portocaval shunt

   • Liver transplantation

Differential diagnoses

Hypovolemia, Internal hemorrhage, Ruptured ectopic pregnancy, Sepsis, Shock