Liver TraumaProf. Ygber González de la Cruz, MD. MsC

Department of Medicine and Therapeutic. SMAHS-UTG

Lecture overview

• Review the main anatomical and

physiological characteristic of the liver.

• Classify the traumatic liver injury.

• Describe the main clinical and

radiological characteristics of the liver

trauma.

• Define the approach to the patient with

a suspected liver trauma at the A & E

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