LIVER INJURIES 01
GIT - 14
Shuja Tahir, FRCS (Edin), FCPS Pak (Hon)
Awais Shuja, MRCS - Faisal Bilal Lodhi, FCPS
! 85% of liver injuries are not bleeding at the time of
! 5-8% of all liver injuries require segmental
! It is common in old age than in children.
! 25% injuries are combined thoracic and abdominal
! 10% of rib fractures of right lower chest are
associated with liver injury.
! 10% of traumatic deaths are due to failure to
diagnose occult abdominal injury during civil life.
! Overall mortality of liver injuries is about 10%
Grade - 5 liver injury ! 70%-90% liver injuries are minor in nature.
! Complex hepatic injuries account for 10-30% of all
Liver is the largest solid intra abdominal organ. It is most injuries.
likely to get injured in any kind of abdominal trauma. The ! Mortality rate of complex hepatic trauma is about
effects of liver injury on haemodynamic stability of the 50%.
patient are very significant. Early and correct assessment ! Penetrating trauma is also increasing. 37% of
helps in the proper management and achievement of penetrating injuries are liver injuries.
better outcome of the treatment. ! Combined thoracic and abdominal injuries are 25%
of all penetrating injuries.
Liver injuries are seen as a part of blunt abdominal ! Bursting type of injuries cause more damage.
trauma, penetrating abdominal trauma, right lower chest
injuries as a consequence of road transport accidents, ETIOLOGY
civil terrorism and war injuries. PENETRATING INJURIES
! Stab wounds 20%
INCIDENCE AND EPIDEMIOLOGY ! Gun shot wound 80%
! Commonly associated with other injuries in 80%
cases. BLUNT INJURIES
! Incidence is getting more common. ! Crush injury
! It is seen following road transport accidents. Mostly ! Blast injury
blunt injuries are secondary to high speed ! Seat belt injury
! It may follow blunt trauma. 60% of blunt trauma IATROGENIC INJURIES
leads to these injuries. ! Biopsy
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LIVER INJURIES 02
! Laparascopic procedures. Liver injuries may be isolated. Most of the time these
! Percutaneous transhepatic cholangiography occur in association with injuries to other abdominal
! Endoscopic procedures viscera as a part of multiorgan trauma. Bony fractures
! Cardiac massage may also be associated with liver injuries.
! Peritoneal dialysis
! Paracentesis Head injuries may be associated with the liver injuries.
The prognosis is poor. There are a number of diagnostic
PATHOLOGY difficulties which are encountered with head injuries.
The pathological changes are seen depending upon ;
! Site of injury. PAIN ABDOMEN
! Size of injury. The patient complains of continuous pain in the right
! Subcapsular tears. hypochondrium. The pain may be of variable intensity.
! Non bleeding lacerations. The pain gets better on resting. The pain may be referred
! Large fractures. to the right shoulder.
! Lobar destruction.
! Vascular injuries of liver. NAUSEA AND VOMITING
! Acceleration and deceleration injuries. The patient with the liver injury may present with nausea
! Blast trauma. and vomiting due to haemoperitoneum. It may be present
! Associated injuries. due to paralytic ileus or peritonitis in the later stages.
! Organs involved in injury.
! Duration of injury before treatment. TENDERNESS & REBOUND TENDERNESS
! General condition of the patient. The right hypochondrial tenderness is felt on palpation of
! Age of the patient. the area. The tenderness may be of severe degree or
palpable on deep palpation. Rebound tenderness may
CLINICAL FEATURES also be present.
HISTORY OF INJURY
The time of injury and mechanism of injury should be GUARDING AND RIGIDITY
noted. Site of injury is suggestive of injury to liver or other These features may be present even in the minor injuries.
organs. Blunt abdominal trauma is likely to injure the solid
organs. Injury to right upper abdomen and lower chest is SHOCK
commonly associated with injuries to liver. Palor, low blood pressure, cold skin, ashen gray color,
thready and fast pulse, cold sweats are the common
If lower right chest injury is present and right lower ribs features of shock. It may be due to large amount of
are fractured, the chances of liver injury are more. intraperitoneal concealed haemorrhage.
Injuries to the right chest are associated with injuries to FEATURES OF PERITONITIS
the liver because of the anatomical site of the liver. The Following features are associated with paralytic ileus or
outcome is poor when multiple organs are involved in the bacterial peritonitis in patients with liver injuries ;
trauma. ! Silent abdomen
Many times patients with blunt injury of abdomen present ! Fluid thrill
with right hypochondrial mass. It may be abdominal wall ! Shifting dullness
haematoma or liver haematoma.
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LIVER INJURIES 03
CULLEN'S SIGN It is positive in patients with haemoperitoneum after 24
hours of injury. There is bruising of the lumbar area
14.02 starting from loin towards the umbilicus. It is because of
extravasation of blood into the subcutaneous tissue of
that area .
Cullen’s Sign The urine examination is a simple investigation. It helps to
pick up associated renal injuries. It also helps to assess
It is commonly known as abdominal black eye. There is the patient in general.
bruising around the umbilicus without any local injury. It is
due to extravasation of blood into the subcutaneous BLOOD EXAMINATION
tissue around the umbilicus. It is positive in patients with Haemoglobin level is performed immediately and serial
haemoperitoneum after 24 hours of the injury1. haemoglobin level estimations are performed at least
twice daily. Progressive decrease is an indication of
GRAY TURNER'S SIGN expanding haematoma.
Total leukocyte count
14.03 Differential leukocyte count
LIVER FUNCTION TESTS
Alkaline phosphatase level
Erect and supine films are exposed to see the Psoas
shadow obliteration, gas shadow under the diaphragm
(pneumoperitoneum), sentinal loops over the area2.
It is performed to see the haemopneumothorax,
Gray Turner’s Sign diaphragmatic hernia and rib fractures if present.
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LIVER INJURIES 04
Sonography performed by emergency surgeons
achieves 81.5% sensitivity and 99.7% specificity. It
seems as if it will replace CT in future as a first line
investigation in the management of blunt injury of
Ultrasonography has almost replaced diagnostic
peritoneal lavage (DPL) as a diagnostic study of first
choice in blunt injury of abdomen8.
Focused assessment sonography in trauma (FAST) CT scan is an excellent investigation which helps in the
diagnosis and grading of liver trauma. It also helps in the
FAST (FOCUSED ASSESSMENT SONOGRAPHY 8,9
monitoring of the patients treated non-operatively .
It is a simple and easily available investigation with high CT scan can demonstrate the haemostasis and healing of
degree of sensitivity and specificity. It is used to see the injured liver. It can pick up the enteric, diaphragmatic and
hemoperitoneum, to see hematoma and the solid organ retroperitoneal injuries as well. It can quantitate haemo-
architecture. It is reliable in detecting intra-abdominal peritoneum10.
solid organ injuries and retroperitoneal injuries.
CT scan has a 100% accuracy in the determination of
This is a very helpful investigation in suspected cases of type and the extent of injury. It is the most sensitive
ruptured liver. It is non invasive and can be performed on diagnostic method for liver trauma.
the bedside of the patient even if the patient is severely
ill. It clearly shows the size and site of rupture of the liver. Most of the liver injuries are diagnosed with non-invasive
methods of investigations confidently. Some of these are
It also shows the peritoneal fluid if present. It can be very minor and don't bleed so much. These can be regularly
effectively used to monitor the cases of hepatic assessed and monitored with the help of ultrasound
haematoma by serial examinations and measurements of scan, CT or MRI scan. It is the single greatest contributing
the changes in the size of the hepatic haematoma. It is a factor allowing the non-operative management of hepatic
versatile and cost affective investigation3,4,5,6,7. injuries.
Repeated ultrasound examination during monitoring of
PERITONEAL TAP, FOUR QUADRANT
the hepatic trauma is very helpful. The lesions, not visible
on initial examination become visible during subsequent
examination. DIAGNOSTIC PERITONEAL LAVAGE (DPL)
These are different methods of detecting the
hemoperitoneum. The first two are less often used now-
Ultrasound examination is accurate enough to predict
a-days as these are invasive and do not confirm the
need for laparotomy in 76.9% cases. Its diagnostic
accuracy varies between 60%-90% depending upon
type of the injured organ .
The peritoneal lavage is progressively being abandoned
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LIVER INJURIES 05
Liver Injury - grade 1 (CT scan) Liver-laceration (Liver trauma)
Liver Injury - grade 2 (CT scan) Grade 2 intra-parenchymal liver injury (CT scan)
Liver trauma - grade 3 (ultrasound scan) Liver trauma - grade 3
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LIVER INJURIES 06
in favour of ultrasound scan as the imaging scans are required.
The role of DPL has diminished due to development of Breathing problems are seen due to decreased
sonography and CT scanning. Its accuracy rate is 98% in respiratory drive and unstable chest wall. It can be
detecting haemoperitoneum. It has following drawbacks ; managed with assisted ventilation. The common causes
! It lacks specificity as to which organ system has of ineffective ventilation after clear and patent airway are;
injured. ! Malposition of endotracheal tube
! It is too sensitive in detecting minute quantities of ! Haemothorax
blood which may lead to non-therapeutic ! Pneumothorax
laparotomies. These can be properly managed after correct diagnosis.
! It is inaccurate in detecting retroperitoneal
and diaphragmatic injuries10,17. C. CIRCULATION
Circulatory support must be started as soon as the
Diagnostic peritoneal lavage is very accurate in the patient is received. The blood should be replaced as
immediate diagnosis of blunt abdominal trauma. it is still quickly as possible. Pulse, blood pressure and central
an investigation of choice at many centres but it is getting venous pressure are good guides for the adequate blood
less popular8. replacement and monitoring the patient.
TREATMENT Loss of blood may also occur from associated injuries. It
should be controlled and stopped as quickly as possible.
The objectives of the treatment are ;
Bleeding from superficial wounds can be controlled by
compression dressing, ligation or stitching of the wound.
Internal bleeding requires surgery and control. The lost
! Assessment of the injury and patient.
amount of blood is replaced with blood or other
! Definitive treatment.
intravenous fluids to keep the circulatory volume as
Standard ABCDE plan is followed as the liver injury is
normal as possible.
associated with other injuries as well.
The hypothermia during the pre-treatment period may
lead to catastrophic effects on outcome of treatment.
The active resuscitative measures are used according to
the standard trauma management plan such as ;
The hypothermia may exacerbate operation room blood
loss independent of degree of physiologic or anatomic
A. AIR WAY injury. Trauma scores and presence of shock correlates
Adequate airway should be secured. The debris and with the development of intra-operative hypothermia.
blood from the oral and tracheo-bronchial passages Hypothermic patients with similar injury severity score
should be mechanically removed or sucked with the help have greater blood loss. Its prevention and correction
of an electric sucker. during resuscitation is most important in reducing the
The airway should be maintained and breathing of patient blood loss .
should be assessed and maintained. Endotracheal
intubation or tracheostomy will ensure clear airway. Simple procedures such as covering the patient with
Assisted ventilatory support should be offered if blankets, infusing warm fluids or blood and irrigating
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LIVER INJURIES 07
peritoneal cavity with warm saline helps to improve the according to the priority.
general condition .
Regular and careful monitoring of the circulatory volume
Regular and careful monitoring of the circulatory volume is done by measurement of pulse and blood pressure
is done by measurement of pulse and blood pressure record, skin perfusion and by calculating urinary output.
record, skin perfusion and calculating urinary output.
ASSESSMENT OF INJURY AND PATIENT
Fresh blood should be transfused in these patients. Fresh INJURY SEVERITY SCORE
frozen plasma and platelet concentrates should be
transfused as well. Major organ system injury Score
Acid base balance should also be maintained as these Moderate 2
patients develop metabolic acidosis which gets worse by
Severe but not life threatening 3
repeated blood transfusions.
Life threatening but survival probable 4
Sodium bicarbonate should be given intravenously slowly Survival not probable 5
to treat the metabolic acidosis. Fatal CVS and neurosurgical injuries 6
Multiorgan trauma is assessed using injury severity
score(ISS). Liver injury may not always be an isolated
The patients with associated brain trauma have various
injury. As multiple organ may be involved in the trauma.
degree of neurological disability.
Injury severity score (ISS) should be performed to plan
the management and anticipate the outcome.
Glasgow coma score should be accurately documented
mentioning clearly whether the patient is paralysed or
All major organ injuries are assessed according to the
scale. Three highest scores are squared and added.
Scores between 25-40 are usually associated with 50%
E. EXPOSURE 12
mortality depending upon the age .
Proper exposure is most important for accurate and
complete examination. The patient should be completely
exposed after adequate resuscitation for re-examination. LIVER INJURY SCALE13
The general assessment of the patient with multiple
injuries is performed by meticulous clinical examination
STRUCTURED EXAMINATION and injury severity scoring. It helps to assess the overall
It is advisable to perform structured examination so that condition of the patient and to predict the outcome of the
nothing is missed and it should be marked on the treatment.
examination check list.
Associated injuries should be documented and treated The isolated liver injury is assessed by liver injury scale. It
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LIVER INJURIES 08
helps in uniform audit of various treatment modalities
and prediction of the outcome of the treatment.
LIVER INJURY SCALE
Grade Injury Description AIS-90
Hematoma Subcapsular,<10% surface area 2
Laceration Capsular tear, <1 cm parenchymal 2
Hematoma Subcapsular, 10%-50% surface area: 2
Intraparenchymal <10 cm in diameter
Laceration Capsular tear, 1-3 cm parenchy- mal 2
depth, <10 cm in length
Grade - 3 liver injury
Hematoma Subcapsular, >50% surface area or 3
expanding : Ruptured subcapsular or
parenchymal hematoma : DEFINITIVE TREATMENT
Intraparenchymal hematoma >10 cm or The outcome of treatment has improved during recent
years. The mortality rate of liver injuries of grade III & IV
Laceration >3 cm parenchymal depth 3 has been brought to nearly under 10% during the last
Laceration Parenchymal disruption involving 25%- 4 decade. It has been helped by following factors ;
75% of hepatic lobe or 1-3 couinaud's
segments within single lobe ! Influence of CT scanning on the non-operative
Laceration Parenchymal disruption involving >75% 5
treatment of adult blunt hepatic trauma.
of hepatic lobe or >3 couinaud's ! Pringle maneuver (portal triad occlusion).
segments within a single lobe
! Topical hypothermia isolated to liver only.
Vascular Juxtahepatic venous injuries i.e. 5 ! Hepatorrhaphy with intrahepatic haemostasis.
retrohepatic vena cava / central major
hepatic veins ! Perihepatic packing and planned re-exploration as a
Vascular Hepatic avulsion 6
part of damage control. The surgery is terminated
under circumstances of haemodynamic instability
* Advance one grade for multiple injuries up to grade III.
! Management of juxtahepatic venous injuries with or
without intracaval shunts.
After initial successful resuscitation, decision is made to
choose the mode of treatment.
Patients who remain hemodynamically unstable after 4
pints of blood transfusion or fluid (after excluding the
blood loss and replacement for associated injuries)
require urgent surgical intervention.
Following modalities of treatment are commonly used for
complex hepatic injuries ;
! Non-operative management
Grade - 1 liver injury
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LIVER INJURIES 09
! Fibrin glue HAEMORRHAGE
! Operative management It is usually diagnosed on clinical examination. The only
differentiation is to be made whether it is hepatic related
NON OPERATIVE MANAGEMENT CRITERIA or from other injuries. Haemodynamic instability is
The patients are selected for non operative management indicative of ongoing haemorrhage and it warrants early
according to the following criteria ; surgical intervention. Failure to embolize the bleeding
! Haemodynamic stability vessel is also an indication for early surgical intervention.
! CT scan delineation of the injury Following errors should be avoided;
! Lack of associated enteric and retroperitoneal
injuries ! The bleeding should not be attributed to non-
! Absence of peritoneal signs. hepatic related causes without CT scan verification.
! Limited number of hepatic related transfusions
during resuscitation and observation period. ! Excessive hepatic-related-blood transfusions
should not be preferred to surgical intervention.
The treatment for suspected liver injuries used to be
immediate laparotomy in patients who had positive ! The pooling of contrast material noted during initial
peritoneal signs and who were haemodynamically scanning should not be under estimated even when
unstable. The patients who used to be haemodynamically patient is haemodynamically stable and grade of
stable, diagnostic peritoneal lavage (DPL) was done and liver trauma is II or less.
surgery was performed if it was positive. Trauma grading
was not done. BILE COLLECTION AND ABSCESSES
Intrahepatic and perihepatic collection of bile (Bilomas)
A very significant observation was noted that majority of occurs in about 0.5%-20% cases15.
patients 67% with blunt abdominal trauma and liver
injuries were not actually bleeding actively when FOLLOW UP AFTER NON-OPERATIVE
laparotomy was done. MANAGEMENT
The non operative management of liver trauma was Patient is advised to refrain from vigorous activities to
restricted to only grade I -III during last decade. Now-a- avoid possibility of haemorrhage for 3-6 months. Liver
days grade IV-V are also being managed non-operatively injuries usually take 3-4 times in healing and restoration
under CT control (repeated CT monitoring). of normal architecture.
Following problems may be faced while undertaking non- The bursting strength of healing liver is near normal or
operative management of blunt hepatic trauma. These better within three weeks of injury.
should be kept in mind and should be avoided ;
Successful non-operative management of the liver
injuries after blunt abdominal trauma has been carried
ASSOCIATED INTRA-ABDOMINAL INJURIES
14 out in about 50%-82% cases during recent years10.
Its incidence is about 5% with isolated hepatic injuries .
Repeated clinical assessment of patient and CT imaging
helps to pick up the initially missed injuries. The FIBRIN GLUE INJECTION
management can be altered accordingly. Fibrin glue is made with highly concentrated human
fibrinogen and clotting factors. It is used to stop the
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LIVER INJURIES 10
bleeding from injured liver and may help in its salvage. to have adequate exposure.
Intra operative resuscitation is carried out.
Fibrin glue can be applied topically in hepatic trauma. It is Complex hepatic injuries grade III and IV are managed by
an effective haemostatic agent. It is even more effective following orderly steps ;
when injected intraparenchymally. It is very useful adjunct ! Portal triad occlusion (Pringle maneuver)
16 ! Finger fracture of hepatic parenchyma (hepa-
to surgery in abdominal trauma .
totomy) to expose hepatic vessels and ducts for
Following precautions should always be taken in cases of repair or ligation.
! Debridement of non-viable hepatic tissue.
non-operative treatment of hepatic trauma; ! Insertion of viable omental pedicle into injury site
! The patient should be hospitalized.
! Lost blood should be replaced. (omentoplasty).
! Antibiotics should be given parenterally. ! Closed suction drainage for grade III and IV hepatic
! Analgesics should be given parenterally. injuries10.
Patient should be kept nil by mouth and on parenteral
fluid and electrolyte therapy till suitable resuscitation.
OPERATIVE MANAGEMENT OF COMPLEX
Grade - 5 liver injury
PORTAL TRIAD OCCLUSION
It is performed with atraumatic vascular clamp and it can
keep the bleeding under control during surgery. It may be
required in nearly 72% of complex hepatic injury
Grade 4 liver injury from a right
thoracoabdominal gunshot wound The occlusion of hepatic vessels may cause hepatic
Ischaemia. The liver can tolerate normothermic
Following surgical procedures are carried out ; ischaemia for 90 minutes. The occlusion should be kept
! Laparotomy and hepatorrhaphy. for lesser period .
! Partial hepatectomy or segmental resection.
! Omental pack or omentoplasty. HEPATORRHAPHY
! Perihepatic packing It is a suitable procedure for grade III to V complex
hepatic injuries. The vessels and ducts are repaired
A long midline incision is used to open the abdomen and under vision. It can be performed after pringle
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LIVER INJURIES 11
Absorbable meshwrapping of burst hepatic injuries 63.
containing viable parenchymal fragments is done.
3. Akgur FM. Tanyel FC. Akhan O. et al. The
VIABLE OMENTAL PACK place of ultrasonographic examination in
Once the bleeding has been controlled, intrahepatic and the initial evaluation of children
perihepatic sepsis is most common complication. It can
be avoided by doing adequate debridement and sustaining blunt abdominal tr auma.
omentoplasty and drainage10. Journal of Pediatric surgery. [JC:jmj]
1993 Jan. 28(1): 78-81.
It may be required in 4-5% of all cases undergoing 4. Rozycki GS. Ochsner MG. Jaffin JH.
operative management. Its indications are ; Champian HR. Prospective evaluation of
! Onset of intra-operative coagulopathy. surgeons use of ultrasound in the
! Failure of other maneuvers to control bleeding. evaluation trauma patients. Journal of
! Presence of bilobar injuries. trauma. [JC:kaf]1993 Apr. 34(4): 516-26:
Closed drainage should be used for grade III to V injuries
and lesser grade injuries may be left undrained. It will 5. Luke FI. Lemire A. St-Vil D. et al. Blunt
keep the sepsis rate to minimum. abdominal tr auma in children. The
pr actical value of ultr asonogr aphy.
COMPLICATIONS Journal of trauma. [JC:kaf]1993 May. 34(5):
! Pulmonary complications 607-10: discussion. 610-1.
! Hypoglycemia 6. Kimwa A. Otsuka T. Emergency centre
! Jaundice ultrasonography in the evaluation of
! Biliary fistulas
! Haemobilia haemoperitoneum: A prospective study.
! Sub diaphragmatic Abscesses. Journal of trauma. [JC:kaf] 1991 Jan.31(1).
! Disseminated intravascular coagulopathy.
7. Roche BG. Bugmann P. Le Coultre C. Blunt
(Most important factor is hypothermia and inadequate injuries to liver, spleen, kidney and
blood component replacement). pancreas in paediatric patients. European
journal of paediatric surgery. [JC: azo]
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