1. The liver is the second most commonly injured organ in abdominal trauma after the spleen. Liver injuries have a high mortality rate, especially with blunt trauma. 2. Liver injuries can be caused by blunt trauma from motor vehicle accidents or falls, as well as penetrating trauma from stab wounds or gunshots. 3. CT scanning is the gold standard for evaluating liver injuries and assessing their severity based on the American Association for the Surgery of Trauma (AAST) grading scale. 4. Management depends on the patient's stability and injury grade. Lower grade injuries may be managed non-operatively but higher grades often require surgery or angiography with embolization.

1. LIVER INJURY
Dr. Haseeb Manzoor
Department Of Radiology
SMCH, Lahore

2. LIVER INJURY
 2nd most commonly injured organ in abdominal trauma after spleen
 Highest mortality rate in abdominal injury ~4.1% to 11.7%
 mortality rate is higher with blunt trauma than with penetrating
trauma
 Right lobe more commonly injured than left

3. AETIOLOGY
 Blunt trauma (e.g. motor vehicle collision, fall, direct blow)
 Penetrating trauma (e.g. gunshot, stabbing)
 Iatrogenic (e.g. percutaneous liver biopsy)

4. ASSOCIATIONS
 bile duct injuries
 right kidney injury
 Adrenal haemorrhage
 Hemoperitoneum
 Retroperitoneal haematoma
 right lower lobe pulmonary contusion/laceration
 haemo/pneumothorax
 right sided rib fractures
 transverse process fractures

5. COMPLICATIONS
 bile duct injury leading to bile peritonitis or biloma
 delayed haemorrhage
 Hepatic or perihepatic abscess
 acute acalculous cholecystitis

6. CLINICAL PRESENTATION
 related to the amount of blood loss
 right upper quadrant pain
 right shoulder tip pain (from diaphragmatic irritation)
 hypotension and shock

7. LABS
Elevated liver transaminases (ALT/AST) ~100% specific and ~93%
sensitive.

8. ULTRASONOGRAPHY
 FAST is readily available & most commonly perfomed investigation.
 It can demonstrate hematomas, contusions, bilomas, and
hemoperitoneum.

9. 62-year-old woman with a history of recent liver biopsy.
a loculated anechoic collection in the liver.

10. 35-year-old male, after sustaining blunt abdominal injury
a crescent-shaped hypoechoic collection along the right lateral aspect
of the liver - subcapsular hematoma

11. 50 yrs , Male
48 hrs follow up after RTA
Heterogeneous echopattern area in right lobe of liver - contusion.
Enlarged right adrenal gland. Right kidney is normal.

12. PLAIN RADIOGRAPH
Non-specific
Associated injuries can be evaluated i.e
 Ribs / vertebral fractures
 Pneumoperitoneum
 major diaphragmatic injury
 gross organ displacement
 metallic foreign bodies

13. N.B
Suspect liver injury in case of Right lower ribs fracture.

14. COMPUTED TOMOGRAPHY
 Contrast enhancedCT is gold standard
 ~95% sensitive and 99% specific
 Grading of liver injury is based on CT findings
 AAST grading is most widely accepted

15. LACERATION:
Irregular linear/branching areas of hypoattenuation
ACTIVE BLEEDING:
Contrast extravasation

16. SUBCAPSULAR HAEMATOMA:
Hypodense elliptical collection between the liver and its capsule
(indents the liver surface)
INTRAPARENCHYMAL HAEMATOMA (CONTUSION):
focal, ill-defined low density areas within the liver parenchyma on
contrast enhancedCT,
or a high density (40-60 HU) area on unenhancedCT

17. 17 yrs, Male , Fell from bike
C+ portal venous phase CT abdomen
"bear claw" laceration of the right hepatic lobe

18. Contrast-enhancedCT
multiple subcapsular hematomas in the right and left lobes (arrows).
Multifocal intraparenchymal hematomas (arrowheads).

19. PITFALLS
 On a contrast enhancedCT, a fatty liver may become isoattenuating
to the laceration / hematoma.
 Focal fatty infiltration may mimic hepatic hematoma, laceration, or
infarction.
 Hepatic lacerations with a branching pattern can mimic unopacified
portal or hepatic veins or dilated intrahepatic bile ducts.
 Beam hardening artifact due to adjacent rib, mimics laceration

20. LIVER INJURY SCALE

21. Proposed by Mirvis et al (1994)
GRADE HEMATOMA
(CENTRAL/SUBCAPSULAR)
LACERATION
1 < 1 CMTHICK
ISOLATED PERIPORTAL BLOOD
TRACKING
CAPSULAR AVULSION
LACERATION <1 CM DEEP
2 < 3 CM <3 CM DEEP,
3 > 3 CM >3 CM DEEP,
4 > 10 CM LOBARTISSUE DESTRUCTION (MACERATION)
OR DEVASCULARISATION
5 BILOBARTISSUE DESTRUCTION (MACERATION)
OR DEVASCULARISATION

22. Proposed by AAST (AmericanAssociation ForThe Surgery OfTrauma)
GRADE HEMATOMA
Sub-capsular Intra-parenchymal
LACERATION
1 <10% surface area - <1 cm parenchymal depth
2 ≤50% surface area <10 cm in diameter ≤3 cm parenchymal depth
3 >50% surface area >10 cm in diameter >3 cm parenchymal depth
4 Expanding / ruptured hematoma with
active bleeding
Parenchymal disruption of ≤75% of A
lobe/
≤3 couinaud segments within A lobe
VASCULAR INJURY
5 Juxtahepatic venous injuries
I.E retrohepatic ivc or central major
hepatic veins
Parenchymal disruption of >75% of A
lobe/
>3 couinaud segments within A lobe
6 Hepatic avulsion -

23. Grade 1 liver injury: 21 years , Female
subcapsular haematoma in segment 7
< 10% of surface area, < 1 cm deep

24. Grade 2 liver injury:
Laceration (< 3 cm deep) in the posterior right hepatic lobe (arrow)
A small fluid collection in the hepatorenal fossa (arrowheads)

25. Grade 3 liver injury: 8 years , Male
Multiple lacerations in right hepatic lobe, >3 cm deep.
Large subcapsular hematoma. no active contrast extravasation

26. Grade 4 liver injury: 35 years, Male
Large laceration in the right lobe of the liver with a perihepatic
haematoma. Active contrast extravastation into the perihepatic space

27. Grade 5 liver injury: 45 years, Male
Liver laceration with involvement of the left hepatic vein, left portal vein
and possibly the IVC. Contrast pooling around the IVC. Large volume
haemoperitoneum.

28. MAGNETIC RESONANCE IMAGING
 limited role
 no advantage over CT scanning
 may be used in follow-up monitoring
 may be used in pregnant women
MRCP can be used for assessment of pancreatic duct / biliary trauma
and its sequelae.

29. ANGIOGRAPHY
 No role in evaluation of unstable patients.
 Demonstrates the site of active bleeding.
 Provides opportunity for transcatheter embolization, which may be
the only treatment required.

30. Selective celiac arteriogram
21 yrs old, male
stabbing injury to the right
upper quadrant
a focal area of hemorrhage in
the right lobe (arrow).
filling defect in the lateral
aspect of the right lobe of
liver due to compression of
liver parenchyma by
subcapsular hematoma.

31. Celiac arteriogram shows contrast extravasation from a branch of the
right hepatic artery (arrow).
Post-embolization angiogram shows embolized microcoils (arrows) and
no further extravasation.

32. MANAGEMENT
 Based on clinical and haemodynamic status of the patient
 unstable haemodynamic status is an Indication for open surgical
intervention
Grade I-II injuries are considered minor
usually require minimal or non operative treatment
Grade III-V injuries are considered severe
usually require surgical intervention
gradeVI injuries are regarded as incompatible with survival

33. Non operative management
If patient is haemodynamically stable
Liver Embolization
If patient is haemodynamically stable/ Low grade liver injury
For controlling active arterial haemorrhage
Damage control surgery
If patient is haemodynamically unstable
Suspicion of Hepatic venous injuries

34. Abdominal trauma/
Suspicion of liver injury
Hemodynamically stable
radiological investigations
No active bleeding
Manage
conservatively
small arterial bleeding
Transcatheter
embolization
Hemodynamically unstable
surgery

35. REFERENCES
http://pubs.rsna.org/doi/full/10.1148/rg.251045079
http://emedicine.medscape.com/article/370508-overview
https://radiopaedia.org/articles/liver-trauma
http://www.aast.org/Library/TraumaTools/InjuryScoringScales.aspx#liver
http://www.radiologyassistant.nl/en/p466181ff61073/acute-abdomen-role-of-ct-in-trauma.html