Liver

In trauma the liver is the second most commonly involved

solid organ in the abdomen after the spleen.
However liver injury is the most common cause of death.
This is due to the fact that there are many major vessels in
the liver, like the IVC, hepatic veins, hepatic artery and portal
vein.
It is important to remember, especially if you are doing
ultrasound, that the posterior segment of the right liver lobe
is the most frequently injured part.
This part also involves the bare area and this can lead to
retroperitoneal bleeding rather than bleeding into the
peritoneal cavity.

Liver laceration with active bleeding

First look at the images on the left of a patient with liver

injury.
Describe the findings.
Then continue.
The findings are:

1. Green arrow: oval shaped hypodense area consistent w

hematoma
2. Yellow arrow: linear shaped hypodense area consistent
with laceration.
Notice that this laceration crosses the left portal vein
3. Blue arrow: vague ill defined hypodense area consisten
with contusion
4. Fluid around the liver
5. There is almost a transsection of the liver, but both lobe
do enhance so there is still normal vascular supply.

Liver injury. The arrows indicate different types of injury.

CT grading system for liver injury

On the left the CT grading system for liver injury, which is
almost the same as the grading system for splenic injury.
The only difference with the spleen is that the liver has two
lobes.
So before you come to grade 5, which is devascularization or
maceration of both lobes, you have grade 4, which is
devascularization or maceration of only one lobe or laceration
greater than 10 cm.
Now regarding the consequences of the CT grading system
the following somewhat conflicting remarks can be made:

Shown to be unreliable in predicting need for surgery

Helpful in guiding management
Positive correlation between grade of injury and the increased
likelihood of failed NOM

First look at the images on the left of a patient with liver

injury.
What are the CT findings in this case?
What is the CT grade of injury?
The findings are the following:

Complete devascularization of the right lobe (i.e. grade 4) .

Contrast blush within the intraparenchymal region, but also
extention beyond the lateral margin of the liver.
Hemoperitoneum.
A second contrast blush at a lower level.

So the next question is: does the presence of a contrast blush

alter the CT grade of injury?
The answer is: it does not, because active bleeding is not part
of the grading system.
However there is increased likelihood of failure of nonoperative management.
Whenever there is a contrast blush, it is important to note if
the contrast blush is associated with a hemoperitoneum and
if it extends beyond the parenchyma, as in this case.
First look at the images on the left of a patient with liver
injury.
What are the CT findings in this case?
What is the CT grade of injury?
The findings are the following:

Subcapsular hematoma greater than 10 cm (i.e. grade 4 inju

Contrast blush
No associated hemoperitoneum

So despite the fact that there is a grade 4 injury and contrast

extravasation, this patient will be treated non-operatively and
probably will do fine, because there is no bleeding into the
peritoneal cavity.
So the important thing to remember it that, the grading
system is of limited help in the management of the patient.
Contrast extravasation on the other hand is of great
importance especially if it is associated with hemoperitoneum
On the left two more examples of laceration.
Lacerations can be stellate, like the example on the left or
branching like the one on the right.

Liver lacerations

First look at the images on the left of a patient with liver

injury.
Ask yourself the following questions:
1. What contrast materials are on board?
2. What is the phase of imaging?
3. Where does the contrast surrounding the liver come
from?

View more images:

There is i.v. contrast and images were taken in the portal

phase.
There is also oral contrast filling of the stomach.
The contrast surrounding the liver could be a result of
stomach or bowel perforation, but since there was no
pneumoperitoneum, this was thought to be unlikely.
So the extravasation was thought to be a result of active
bleeding and since there is a great amount of contrast
surrounding the liver, this was thought to be a huge leak.

1/3

At the OR an avulsed right hepatic vein was found.

This diagnosis has a 90-100% mortality and this patient died
in the OR.
Some final remarks conceirning liver injury:

Historically liver injury was managed surgically, but at

laparotomy it was found that 70% of the bleedings had alrea
stopped by the time the surgeons got there.
Importantly, patients who went for surgery had more
transfusions and more complicaties than patients who were
treated non-operatively.
Today about 80% is managed non-operatively.
Delayed complications occur in 10-25% of all patients and
include:
o hemorrhage (2-6%)
o hepatic abscess (1-4%)
o biloma (<1%)