7/27/2019 Liver Trauma 1

1/24

Liver Trauma

Vic Vernenkar, D.O.St. Barnabas Hospital

7/27/2019 Liver Trauma 1

2/24

Background

Largest solid abdominal organ,fixed positionSecond most common injured, but mostcommon cause of death after abdominaltrauma

Blunt MVA most common80% adults, 97% children-conservative rx

7/27/2019 Liver Trauma 1

3/24

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 diaphragmTransmission thru right hemithorax.

7/27/2019 Liver Trauma 1

4/24

Pathophysiology

Liver injured easily in children since ribsare compliant, force transmitted.Liver not as developed in children, withweaker connective tissue framework.Iatrogenic injuries by biopsies, biliarydrainage, TIPS, can cause capsular tearsand bile leaks, fistulas, hemoperitoneum.

7/27/2019 Liver Trauma 1

5/24

Injuries

Subcapsular hematoma or intrahepatichematoma.

LacerationContusionHepatic vascular disruptionBile duct injury86% of injuries have stopped bleeding at time of exploration.Decreased transfusion req.With conservative.

7/27/2019 Liver Trauma 1

6/24

Injuries

Mild hepatic injuries involving < 25% of one lobe heal in 3 mos.Moderate injuries involving 25-50% of onelobe heal in 6 mos.Sever injuries require 9-15 mos to heal.Gallbladder injuries rare, with contusons

being most common, avulsions next most.

7/27/2019 Liver Trauma 1

7/24

Anatomy

Cantile described main divisions along amain plane from GB fossa to IVC. Dividesliver into equal halves.Couinaud developed 4 sectors and 8segments, divided into vertical and oblique

planes, defined by the 3 main hepatic veinsand transverse plane thru right and left

portal branches.

7/27/2019 Liver Trauma 1

8/24

Anatomy

Hepatic veins lie between segments.Left hepatc vein divides left lobe intomedial and lateral segments.Middle hepatic vein divides liver into leftand right lobes.

7/27/2019 Liver Trauma 1

9/24

Anatomy

Right hepatic vein divides right lobe intoanterior and posterior segments.

A horizontal line thru left and right main portal veins is used to divide lobes intoinferior and superior segments.

The 8 liver segments are numbersclockwise on the frontal view.

7/27/2019 Liver Trauma 1

10/24

Liver Segments

7/27/2019 Liver Trauma 1

11/24

Liver Segments

7/27/2019 Liver Trauma 1

12/24

Clinical Details

Symptoms of injury are related to bloodloss, peritoneal irritation, RUQ tenderness,

and guarding.Unrecognized delayed abcessBilomasSigns of blood loss may dominate the

picture.

7/27/2019 Liver Trauma 1

13/24

Clinical Details

Elevated liver testsBiliary 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.

7/27/2019 Liver Trauma 1

14/24

Limitations

FAST sensitivity highest (98%) for grade 3injuries or greater. Negative findings do not

exclude hepatic injury.Emergency sono findings demonstrating freefluid, parenchymal injury, or both demonstrateoverall sensitivity for detection of bluntabdominal trauma of 72%.Angiogram may fail to detect active bleeding.

7/27/2019 Liver Trauma 1

15/24

CT Scans

Accurate in localizing the site of liver injury, associated injuries.

Used to monitor healing.CT criteria for staging liver trauma usesAAST liver injury scale

Grades 1-6Hematoma,laceration,vascular,acute

bleeding,gallbladder injury,biloma.

7/27/2019 Liver Trauma 1

16/24

Classification

I-Subcapsular hematoma 3cm diameter.

7/27/2019 Liver Trauma 1

17/24

Classification

IV-Parenchymal/supcapsular hematoma>10cm in diameter, lobar destruction, or

devasularization.V- Global destruction or devascularizationof the liver.

VI-Hepatic avulsion

7/27/2019 Liver Trauma 1

18/24

Angiography

Demonstrates active bleedingTranscatheter embolization may be theonly treatment required.Findings include contusion, laceration,hematoma, pseudoaneurysms, fistulas.Embolization can reduce transfusionrequirements, stenting for fistulas.

7/27/2019 Liver Trauma 1

19/24

Angiography

7/27/2019 Liver Trauma 1

20/24

Grade I Liver Injury

7/27/2019 Liver Trauma 1

21/24

Grade II Liver Injury

7/27/2019 Liver Trauma 1

22/24

Grade III

7/27/2019 Liver Trauma 1

23/24

Grade IV

7/27/2019 Liver Trauma 1

24/24

Grade V