The document discusses liver trauma, providing details on the anatomy and physiology of the liver, classifications of traumatic liver injuries, clinical presentations, diagnostic imaging approaches including CT scans and angiography, and treatments. Key points covered include: the liver is the second most commonly injured abdominal organ from trauma but most common cause of death; injuries are often from blunt force such as motor vehicle accidents; CT scans are the diagnostic standard and can classify injuries on a scale of I-VI based on features like hematomas and lacerations; angiography can identify active bleeding for potential embolization treatment.
1. Liver Trauma
Prof. Ygber González de la Cruz, MD. MsC
Department of Medicine and Therapeutic. SMAHS-UTG
2. 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
3. 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
4. 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.
5. 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.
6. 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.
7. 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.
8. 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.
9. 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.
10. 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.
13. 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.
14. 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.
15. 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.
16. 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.
17. 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.
18. Classification
• IV-Parenchymal/supcapsular
hematoma> 10cm in diameter, lobar
destruction, or devasularization.
• V- Global destruction or
devascularization of the liver.
• VI-Hepatic avulsion
19. 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.