ruptur hepar

Download Ruptur Hepar

Post on 11-Jul-2016

7 views

Category:

Documents

0 download

Embed Size (px)

DESCRIPTION

management

TRANSCRIPT

  • HistoryHistory

    Basic data: Basic data: ** 4545 AdmissionAdmission date: 2007/09/12date: 2007/09/12

    Chief complaint: Chief complaint: diffuse abdominal pain after traffic accidentdiffuse abdominal pain after traffic accident

  • Present illness:Present illness: On Sep. 12 about 21:40, he drove a car and hit On Sep. 12 about 21:40, he drove a car and hit

    against traffic island. According to the first aider, against traffic island. According to the first aider, there was alcoholic odor on his body and blood in there was alcoholic odor on his body and blood in his oral and nasal cavity. There was no open his oral and nasal cavity. There was no open wound and active bleeding in appearance.wound and active bleeding in appearance.

    PE:PE: TPR: 35.2 / 80 / 18 ; BP: 92/63 mmHgTPR: 35.2 / 80 / 18 ; BP: 92/63 mmHg Consciousness: E3M6V5, drowsyConsciousness: E3M6V5, drowsy Abdomen: soft and distension, diffuse tenderness, Abdomen: soft and distension, diffuse tenderness,

    rebounding pain(+), hypoactive bowel soundrebounding pain(+), hypoactive bowel sound

  • Lab Data:Lab Data: Blood gas: pH=7.295, pCO2=32.6, HCO3=15.4, Blood gas: pH=7.295, pCO2=32.6, HCO3=15.4,

    pO2=57.1, pO2=57.1, ABEcABEc==--9.7, 9.7, SBEcSBEc==--9.89.8 GOT/GPT= 297/230, GOT/GPT= 297/230, U/A: OB=2+U/A: OB=2+

    Bedside abdominal echo: Bedside abdominal echo: No fluid seenNo fluid seen

    Abdominal CT:Abdominal CT:

  • Impression: liver laceration, grade IVImpression: liver laceration, grade IV

    Treatment: Treatment: Sep. 13th, 2:35AMSep. 13th, 2:35AM hepatorrhaphyhepatorrhaphy + repair of + repair of

    portal vein and hepatic veinportal vein and hepatic veinliver laceration of S4~S7liver laceration of S4~S7

    Sep. 13th, 9:50AMSep. 13th, 9:50AM Partial Partial segmentectomysegmentectomy(S4~S6)(S4~S6)

    Died on Sep. 14th, 10:40AMDied on Sep. 14th, 10:40AM

  • DiscussionDiscussion

  • Mechanism of liver injuryMechanism of liver injury 2 categories of blunt liver trauma:2 categories of blunt liver trauma:

    Deceleration trauma Deceleration trauma fall from heightfall from heightcreate fissure in the hepatic parenchyma, typically between create fissure in the hepatic parenchyma, typically between

    right posterior and right anterior sector, may involve major right posterior and right anterior sector, may involve major vesselsvessels

    Crush injury Crush injury direct trauma to the abdomen over liver direct trauma to the abdomen over liver areaarea

    Penetrating trauma may not associate with Penetrating trauma may not associate with parenchymalparenchymaldisruption, but life threatening hemorrhage if major disruption, but life threatening hemorrhage if major vessel is transectedvessel is transected

  • Symptoms & SignsSymptoms & Signs Shock, hypotensionShock, hypotension Abdominal distensionAbdominal distension Anterior abdominal wall bruisingAnterior abdominal wall bruising Abdominal painAbdominal pain Peritoneal signsPeritoneal signs Shoulder tip pain (Shoulder tip pain (subdiaphragmaticsubdiaphragmatic hematoma causing hematoma causing phrenicphrenic

    nerve irritation) nerve irritation) Penetrating low thoracic woundPenetrating low thoracic wound Posterior penetrating wound below scapulaPosterior penetrating wound below scapula Abdominal Abdominal sonographysonography: : intraperitonealintraperitoneal fluidfluid Diagnostic peritoneal Diagnostic peritoneal lavagelavage (DPL): blood(DPL): blood CT: blood, collapsed cava, shock CT: blood, collapsed cava, shock nephrogramnephrogram, small , small hypodensehypodense

    spleen (gold stander)spleen (gold stander)

  • Image GradingImage Grading

    CT in Blunt Liver Trauma. Woong Yoon, MD ; RadioGraphics 2005; 25:87104

  • TreatmentTreatment

    Hemodynamicallystable:

    Diagnosis and management of blunt abdominal solid organ injury.Thomas J. Schroeppel ; Current Opinion in Critical Care 2007, 13:399404

  • IVF challengeIVF challenge Blood transfusionBlood transfusion Angiographic Angiographic embolizationembolization Monitor Monitor HctHct and vital signsand vital signs

  • Hemodynamicallyunstable:

    DPL: diagnostic peritoneal lavageFAST: focused assessment by

    sonography for trauma

    Diagnosis and management of blunt abdominal solid organ injury.Thomas J. Schroeppel ; Current Opinion in Critical Care 2007, 13:399404

  • Operation: Operation: Principles: control of bleeding, removal of Principles: control of bleeding, removal of

    devitalized tissue, adequate drainagedevitalized tissue, adequate drainage Simple suture with or without Simple suture with or without hemostatichemostatic agentsagents Deep mattress sutureDeep mattress suture PackingPacking DebridementDebridement ResectionResection Mesh Mesh hepatorrhaphyhepatorrhaphy

  • PrognosisPrognosis

    Overall mortality rate: 8~10% ; morbidity rate: Overall mortality rate: 8~10% ; morbidity rate: 18~30%18~30%

    NonoperativeNonoperative management:management: Grade 1~3: success rate near 95%Grade 1~3: success rate near 95% Grade 4~5: success rate 75~80%Grade 4~5: success rate 75~80% Complication rate 11%: Complication rate 11%: most could be managed with most could be managed with

    angioembolizationangioembolization for contrast for contrast extravasationextravasation, CT, CT--guided guided drainage for hepatic abscess and drainage for hepatic abscess and bilomasbilomas, laparoscopy for bile , laparoscopy for bile peritonitis, and endoscopic retrograde peritonitis, and endoscopic retrograde cholangiopancreatographycholangiopancreatography (ERCP) for persistent bile leaks.(ERCP) for persistent bile leaks.

  • Operative management:Operative management: Operative mortality is 20Operative mortality is 2043%43% Complication: postoperative bleeding(10%), intraComplication: postoperative bleeding(10%), intra--

    abdominal abscess(7.2%), abdominal abscess(7.2%), biliarybiliary fistula (7~10%), fistula (7~10%), hemobilia(rarehemobilia(rare))

  • ReferencesReferences SabistonSabiston: textbook of surgery. 17th ed.: textbook of surgery. 17th ed. Emergency Emergency imageingimageing. R. Brooke Jeffery, 1st ed.. R. Brooke Jeffery, 1st ed. HepatobiliaryHepatobiliary and pancreatic surgery. O. James and pancreatic surgery. O. James

    Garden, 2nd ed.Garden, 2nd ed. Diagnosis and management of blunt abdominal solid Diagnosis and management of blunt abdominal solid

    organ injury. Thomas J. organ injury. Thomas J. SchroeppelSchroeppel ; Current Opinion ; Current Opinion in Critical Care 2007, 13:399in Critical Care 2007, 13:399404404

    CT in Blunt Liver Trauma. CT in Blunt Liver Trauma. WoongWoong Yoon, MD ; Yoon, MD ; RadioGraphicsRadioGraphics 2005; 25:872005; 25:87104104

    Advances and Changes in the Management of Liver Advances and Changes in the Management of Liver Injuries. SEONG K. LEE ; THE AMERICAN Injuries. SEONG K. LEE ; THE AMERICAN SURGEON March 2007, 201SURGEON March 2007, 201--206206