Liver Trauma

trauma liver
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  Liver Liver laceration with active bleeding In trauma the liver is the second most commonly involved solid organ in the abdomen after the spleen. However liver injury is the most common cause of death. This is due to the fact that there are many major vessels in the liver, like the IVC, hepatic veins, hepatic artery and portalvein. It is important to remember, especially if you are doing ultrasound, that the posterior segment of the right liver lobe is the most frequently injured part. This part also involves the bare area and this can lead to retroperitoneal bleeding rather than bleeding into the peritoneal cavity. Liver injury. The arrows indicate different types of injury. First look at the images on the left of a patient with liver injury. Describe the findings. Then continue. The findings are: 1.   Green arrow: oval shaped hypodense area consistent hematoma 2.   Yellow arrow: linear shaped hypodense area consistenwith laceration. Notice that this laceration crosses the left portal vein 3.   Blue arrow: vague ill defined hypodense area consistewith contusion 4.   Fluid around the liver 5.   There is almost a transsection of the liver, but both lobdo enhance so there is still normal vascular supply. CT grading system for liver injury  On the left the CT grading system for liver injury, which is almost the same as the grading system for splenic injury. The only difference with the spleen is that the liver has two lobes. So before you come to grade 5, which is devascularization or maceration of both lobes, you have grade 4, which is devascularization or maceration of only one lobe or laceratiogreater than 10 cm. Now regarding the consequences of the CT grading system the following somewhat conflicting remarks can be made: Shown to be unreliable in predicting need for surgery Helpful in guiding management Positive correlation between grade of injury and the increaselikelihood of failed NOM    First look at the images on the left of a patient with liver injury. What are the CT findings in this case? What is the CT grade of injury? The findings are the following: Complete devascularization of the right lobe (i.e. grade 4) . Contrast blush within the intraparenchymal region, but also extention beyond the lateral margin of the liver. Hemoperitoneum. A second contrast blush at a lower level. So the next question is: does the presence of a contrast blusalter the CT grade of injury? The answer is: it does not, because active bleeding is not parof the grading system. However there is increased likelihood of failure of non-operative management. Whenever there is a contrast blush, it is important to note if the contrast blush is associated with a hemoperitoneum and if it extends beyond the parenchyma, as in this case. First look at the images on the left of a patient with liver injury. What are the CT findings in this case? What is the CT grade of injury? The findings are the following: Subcapsular hematoma greater than 10 cm (i.e. grade 4 inj   Contrast blush No associated hemoperitoneum So despite the fact that there is a grade 4 injury and contrast extravasation, this patient will be treated non-operatively anprobably will do fine, because there is no bleeding into the peritoneal cavity. So the important thing to remember it that, the grading system is of limited help in the management of the patient. Contrast extravasation on the other hand is of great importance especially if it is associated with hemoperitoneum Liver lacerations On the left two more examples of laceration. Lacerations can be stellate, like the example on the left or branching like the one on the right.   View more images: 1/3 First look at the images on the left of a patient with liver injury. Ask yourself the following questions: 1.   What contrast materials are on board? 2.   What is the phase of imaging? 3.   Where does the contrast surrounding the liver come from? There is i.v. contrast and images were taken in the portal phase. There is also oral contrast filling of the stomach. The contrast surrounding the liver could be a result of stomach or bowel perforation, but since there was no pneumoperitoneum, this was thought to be unlikely. So the extravasation was thought to be a result of active bleeding and since there is a great amount of contrast surrounding the liver, this was thought to be a huge leak. At the OR an avulsed right hepatic vein was found. This diagnosis has a 90-100% mortality and this patient died in the OR. Some final remarks conceirning liver injury: Historically liver injury was managed surgically, but at laparotomy it was found that 70% of the bleedings had alrestopped by the time the surgeons got there. Importantly, patients who went for surgery had more transfusions and more complicaties than patients who were treated non-operatively. Today about 80% is managed non-operatively. Delayed complications occur in 10-25% of all patients and include: o   hemorrhage (2-6%) o   hepatic abscess (1-4%) o   biloma (<1%)


Jul 23, 2017

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Jul 23, 2017
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