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 portal vein. 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 laceration with active bleeding
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 w
hematoma 2. Yellow arrow: linear shaped hypodense area consistent with laceration. Notice that this laceration crosses the left portal vein 3. Blue arrow: vague ill defined hypodense area consisten with contusion 4. Fluid around the liver 5. There is almost a transsection of the liver, but both lobe do enhance so there is still normal vascular supply.
Liver injury. The arrows indicate different types of injury.
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 laceration greater 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 increased likelihood 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 blush
alter the CT grade of injury? The answer is: it does not, because active bleeding is not part of the grading system. However there is increased likelihood of failure of nonoperative 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 inju
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 and probably 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 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.
Liver lacerations
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?
View more images:
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.
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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 alrea stopped 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%)