Case Presentation

Dr Mohammad Tallal Abdullah

Post Graduate Resident

Surgical Unit ll

SHL

History

• A 19 year old male

• Presented in surgical emergency with history of road side accident about 3 hrs back

• Patient was riding on bike

• Hit by a Mazda loader from the side and was dragged along the vehicle for some distance on road

Physical examination

• Pulse 100 bpm

• B.P 90/60

• R/R 22 /min

• O2 sat 95%

• Airway was clear

• C-spine was intact

• Relatively reduced air entry on right side of chest with subcutaneous emphysema

• Imprint sign over right hypochondrium

• Abdomen was tender and tense with positive guarding sign

• Pelvis stable

• All four limbs normal

• There was no obvious bleeding seen at the time of presentation

• There were no signs and symptoms of head injury

• Patient had a GCS of 15/15 and was responding to verbal commands

Management• Chest intubation

• Main goal: Resuscitation

• 2 wide bore IV lines

• I/V Fluids rushed

• I/V Analgesia

• Anti tetanus toxoid

• I/V Antibiotic

• Nasogastric tube

• Catheterization

• Vitals monitoring

Workup

• CBC: Hb 11.5TLC 15,000

• RFTs: ALT 60• Other baseline investigations unremarkable • blood grouping and cross matching• CXR• FAST scan (moderate amount of fluid in

abdomen and pelvis)• urine examination• CT scan

LIVER TRAUMA

• Liver is one of the most commonly injured organs in abdominal trauma.

• Most common cause is blunt abdominal trauma which is usually as a result of RTA.

• Liver trauma can either be due to:#Blunt abdominal trauma#Penetrating abdominal trauma#Iatrogenic

Grading Of Traumatic Liver Injury

Traumatic liver injury can be graded according to either:

-hepatic hematoma

-or hepatic laceration

And at worse, major vascular injury/avulsion is graded as grade 6

Grade IHematoma: Subcapsular, nonexpanding, < 10% surface area.Laceration: Capsular tear, nonbleeding, < 1cm deep.

Grade IIHematoma: Subcapuslar, nonexpanding, 10-50% surface area; intraparenchymal, nonexpanding, < 2cm diameter.Laceration: Capsular tear, active bleeding; 1-3cm deep, < 10cm in length.

Grade IIIHematoma: Subcapsular, > 50% surface area or expanding; ruptured subcapsular hematoma with active bleeding.Laceration: Intraparenchymal hematoma > 2cm or expanding; > 3cm deep.

Grade IVHematoma: Ruptured intraparenchymal hematoma with active bleeding.Laceration: Parenchymal disruption involving 25-50% of hepatic lobe.

Grade VLaceration: Parenchymal disruption involving > 50% of hepatic lobe.

Grade VIVascular: Juxtahepatic venous injury; ie. Retrohepatic vena cava / major hepatic veins, hepatic avulsion.

Grade I

Hematoma: Subcapsular, nonexpanding, < 10% surface area.Laceration: Capsular tear, nonbleeding, < 1cm deep.

Grade II

Hematoma: Subcapuslar, nonexpanding, 10-50% surface area; intraparenchymal, nonexpanding, < 2cm diameter.Laceration: Capsular tear, active bleeding; 1-3cm deep, < 10cm in length.

Grade III

Hematoma: Subcapsular, > 50% surface area or expanding; ruptured subcapsular hematoma with active bleeding.Laceration: Intraparenchymal hematoma > 2cm or expanding; > 3cm deep.

Grade IV

Hematoma: Ruptured intraparenchymal hematoma with active bleeding.Laceration: Parenchymal disruption involving 25-50% of hepatic lobe.

Grade V

Laceration: Parenchymal disruption involving > 50% of hepatic lobe.

Management

Conservative

• Hemodynamically stable patients with abdominal trauma with mild to moderate grade of liver injury (1-3)

• Hollow viscus injuries must have been ruled out

Surgical

• Hemodynamically unstable patients with deterioration during observation

• All grade 4 and above hepatic injuries

• Gunshot or stab wound with penetration of peritoneum

Surgical options

• Exploratory laparotomy is done and primary focus is to secure hemostasis. 4 P’s

• ‘Push’. Traumatized liver is manually closed

• ‘Pringle’. Hemostatic clamp over hepatoduodenalligament

• ‘Plug’. Any penetrating injury to liver can be plugged.

• ‘Pack’

• Other options include hepatotomy, suturing, parenchymal resection, vascular repair and ligation

Back to case….

• Exploratory laparotomy done revealing:

i. 1.5 litre hemoperitoneum

ii. Laceration of hepatic segment V, Vl, Vll,

iii. Suspicion of biliary leakage

Buttress sutures applied to the major segment Vl laceration And Liver Packing was done…

3 pints of whole blood transfused peroperatively

Patient shifted to SICU on ventilator where he remained hemodynamically stable

• Packs removed after 48 hours. Hemostasis was secured.

• There was evidence of biliary leakage but exact site couldn’t be identified…

A subhepatic drain was placed then..

Patient had a drain output averaging 100-150 ml each day. Yellow in color

With persistent C/O pain epigastrium associated with nausea.

Recurrent episodes of fever not settling with antibiotics.

BILIARY FISTULA

Biliary Fistula

• The most common accepted definition of a bile leak requires the presence of the following:– bile discharge from an abdominal wound and/or

drain, with a total bilirubin level of >5 mg/mL or three times the serum level

– intra-abdominal collections of bile confirmed by percutaneous aspiration

– cholangiographic evidence of dye leaking from the opacified bile ducts

World Journal of Surgery, vol. 27, no. 6, pp. 695–698, 2003.

ETIOLOGY

• Bile leaks mainly result from injury to theextrahepatic bile duct during cholecystectomy.

• A bile leak from the intrahepatic biliary tree isless frequent and generally follows liver surgery

• After blunt or penetrating abdominal trauma

• Less commonly, bile leaks from the liver mayresult following drainage of a liver abscess ornonsurgical ablation of liver lesions / hydatidcysts.

Natural Progression

• Most bile leaks settle spontaneously

• Others will settle with interventions such asERCP.

• Only a few require surgical management inthe form of hepaticojejunostomy.

Types

• Nagano et al. have classified postoperative bile leaks into four types :

• Type A: minor leaks from small bile radicles on the surface of the liver which are usually self-limiting,

• Type B: leaks from inadequate closure of the major bile duct branches on the liver’s surface,

• Type C: injury to the main duct commonly near the hilum,

• Type D: leakage due to a transected duct disconnected from the main duct.

Management - Overview

• Type A leaks usually close spontaneously with external drainage although sometimes ERCP and sphincterotomy may be required.

• Types B and C can be managed by ERCP and stenting combined with drainage of the bile collection.

• Type D leaks require surgery and bilioentericanastomosis or, if the draining segment is small, fibrin glue occlusion or acetic acid ablation. Sometimes operative excision of the excluded segment may be required [10,11].

Bile leaks after liver trauma –(Non-iatrogenic)

• Overall the incidence of intrahepatic bile ductinjury after blunt trauma for all grades ofinjury varies from 2.8% to 7.4%

• Bile leaks can lead to significant morbidityafter liver trauma.

• Influx of bile into the hematoma may increasethe pressure within it, leading to necrosis ofthe surrounding liver tissue and formation of abiloma

• 2/3rd of patients with blunt abdominal trauma requiring surgery develop bile leaks

• Of those managed conservatively only 17% develop bile leaks.

Management

• Most cases of bile duct injury after blunt trauma present as bilomas which can be managed conservatively.

• Rest can be managed by ERCP

• Bile peritonitis which requires laparotomy and drainage may also be managed by a minimal invasive combination of laparoscopic lavage and ERCP decompression

• Surgery is required only for type D fistulas.

Coming back to our case

• ERCP with stenting was done.

• A bile leak from a lateral rent in CBD was noted.

• A stent was passed across the laceration.

• Patients was successfully managed and discharged 4 days after ERCP.