Liver Trauma

Vic Vernenkar, D.O.

St. Barnabas Hospital
 Background
 Largest solid abdominal organ,fixed
position
 Second most common injured, but most
common cause of death after abdominal
trauma
 Blunt MVA most common
 80% adults, 97% children-conservative rx
 Pathophysiology
 Friable parenchyma, thin capsule, fixed
position in relation to spine.
 Right lobe gets hit more since its larger,
and closer to ribs.
 85% injuries involve segments 6,7,8 from
compressioin against ribs, spine, abd wall.
 Shear forces at attachments to diaphragm
 Transmission thru right hemithorax.
 Pathophysiology
 Liver injured easily in children since ribs
are compliant, force transmitted.
 Liver not as developed in children, with
weaker connective tissue framework.
 Iatrogenic injuries by biopsies, biliary
drainage, TIPS, can cause capsular tears
and bile leaks, fistulas, hemoperitoneum.
 Injuries
 Subcapsular hematoma or intrahepatic
hematoma.
 Laceration
 Contusion
 Hepatic vascular disruption
 Bile duct injury
 86% of injuries have stopped bleeding at time of
exploration.
 Decreased transfusion req.With conservative.
 Injuries
 Mild hepatic injuries involving < 25% of
one lobe heal in 3 mos.
 Moderate injuries involving 25-50% of one
lobe heal in 6 mos.
 Sever injuries require 9-15 mos to heal.
 Gallbladder injuries rare, with contusons
being most common, avulsions next most.
 Anatomy
 Cantile described main divisions along a
main plane from GB fossa to IVC. Divides
liver into equal halves.
 Couinaud developed 4 sectors and 8
segments, divided into vertical and oblique
planes, defined by the 3 main hepatic veins
and transverse plane thru right and left
portal branches.
 Anatomy
 Hepatic veins lie between segments.
 Left hepatc vein divides left lobe into
medial and lateral segments.
 Middle hepatic vein divides liver into left
and right lobes.
 Anatomy
 Right hepatic vein divides right lobe into
anterior and posterior segments.
 A horizontal line thru left and right main
portal veins is used to divide lobes into
inferior and superior segments.
 The 8 liver segments are numbers
clockwise on the frontal view.
Liver Segments
Liver Segments
 Clinical Details
 Symptoms of injury are related to blood
loss, peritoneal irritation, RUQ tenderness,
and guarding.
 Unrecognized delayed abcess
 Bilomas
 Signs of blood loss may dominate the
picture.
 Clinical Details
 Elevated liver tests
 Biliary peritonitis (nausea, vomiting, abd
pain).
 DPL has high sensitivity, 1-2%
complication rate.
 Plain x-rays non-specific.
 CT scan diagnostic procedure of choice.
 Hida for leaks, angio for hemorrhage.
 Limitations
 FAST sensitivity highest (98%) for grade 3
injuries or greater. Negative findings do not
exclude hepatic injury.
 Emergency sono findings demonstrating free
fluid, parenchymal injury, or both demonstrate
overall sensitivity for detection of blunt
abdominal trauma of 72%.
 Angiogram may fail to detect active bleeding.
 CT Scans
 Accurate in localizing the site of liver
injury, associated injuries.
 Used to monitor healing.
 CT criteria for staging liver trauma uses
AAST liver injury scale
 Grades 1-6
 Hematoma,laceration,vascular,acute
bleeding,gallbladder injury,biloma.
 Classification
 I-Subcapsular hematoma<1cm, superficial
laceration<1cm deep.
 II-Parenchymal laceration 1-3cm deep,
subcapsular hematoma1-3 cm thick.
 III-Parenchymal laceration> 3cm deep and
subcapsular hematoma> 3cm diameter.
 Classification
 IV-Parenchymal/supcapsular hematoma>
10cm in diameter, lobar destruction, or
devasularization.
 V- Global destruction or devascularization
of the liver.
 VI-Hepatic avulsion
 Angiography
 Demonstrates active bleeding
 Transcatheter embolization may be the
only treatment required.
 Findings include contusion, laceration,
hematoma, pseudoaneurysms, fistulas.
 Embolization can reduce transfusion
requirements, stenting for fistulas.
Angiography
Grade I Liver Injury
Grade II Liver Injury
Grade III
Grade IV
Grade V