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Liver Trauma . 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.
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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.
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.
