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ABSTRACT
Even with todays modern surgical techniques and sophisticated intensive
care units, management of the traumatic liver injury still represents a
major challenge to the most highly experienced trauma surgeons. In the
last century, there was constant debate regarding the most appropriate
management of these often critically ill patients. This is because hepatic
injuries carry the potential for catastrophic exsanguination due to the highly
vascular nature of this organ. Mortality and morbidity rise dramatically after
high grade liver injury, but often these result from the associated injuries
incurred due to the mechanism and severity of the injury. In Australia,
blunt trauma is the predominant mechanism of injury, often from high
speed motor vehicle accidents. However, in other parts of the world and
particularly in areas of conflict, penetrating trauma represents a significant
cause of hepatic trauma. This article provides an overview for health care
professionals, who in their every day practice may encounter the patient
with hepatic trauma.
successful treatment modality for
blunt liver trauma (3-5). This treatment
strategy gained momentum in the late
80s and within a decade had become the
mainstay strategy for managing blunt
liver trauma. It is intriguing that as early
as 1887; Edler was reportedly managing
several hundreds of patients with liver
trauma non-operatively (3).
EPIDEMIOLOGY AND
PATHOPHYSIOLOGY
The anatomical location of the liver, its
size and the large surface area of the
upper abdomen and trunk account for
the high proportion of liver injuries seen
in trauma patients suffering from both
blunt and penetrating trauma (6-9). The
spleen and kidneys are the other solid
organs commonly involved under these
circumstances. Moores grading system
for liver trauma, which depicts the range
of injuries which can be sustained to a
patients liver, is presented in Table 1 (10).
Grade
indicates
minor
injury
Table 1: Grading of Liver Trauma (adapted from the American Association for the Surgery of Trauma (AAST) guidelines (10)
Grade
Injury
Description
Haematoma
Laceration
II
III
Haematoma
Laceration
Haematoma
Laceration
IV
Laceration
Laceration
Vascular
Vascular
Hepatic avulsion
VI
liver (13).
ASSOCIATED INJURIES
Any injury which is significant enough
to cause liver trauma often causes
multiple injuries to other viscera and
body regions. Over 80% of patients
with liver injuries may have one
or more associated injuries (5). In
blunt hepatic trauma, chest injuries
are the most commonly associated
injury followed by long bone and
pelvis fracture, intrabdominal solid
organs (spleen) and head injuries
(5). In penetrating trauma, the small
bowel, colon, diaphragm, stomach
and kidneys are commonly involved
whilst the spleen and pancreas are
uncommonly injured (5,7). Ultimately
it is these injuries which can lead to a
detrimental or fatal outcome for the
patient. Injury to vascular structures
carries a particularly dire prognosis
(5,7,12). In fact, the presence of a major
abdominal vascular injury (the inferior
Figure 1: Transverse CT scan of a patient with severe blunt hepatic trauma showing extensive
haematoma and arterial blush (grade IV). The patient underwent angiography with succesful
embolisation of the bleeding vessel. Source: courtesy of Dr. Sivakumar Gananadha, Upper
Gastrointestinal Unit, The Canberra Hospital
Figure 2: Coronal CT scan of the same patient in figure 1 demonstrating the arterial blush (arrow).
Source: Courtesy of Dr. Sivakumar Gananadha, Upper Gastrointestinal Unit, The Canberra Hospital
ligament),
simple
suture
and
compression, hepatotomy and vascular
ligation, and finally, in the most dire
of circumstances the atriocaval shunt
may be employed as a last ditch effort
to obtain haemodynamic control.
Stone et al. advised that for the surgeon
faced with the desperate situation in
the operation room, the use of sutures
on a large curved needle combined
with packing is advised (9). Whilst
the choice of technique to achieve
haemostasis after packing still remains
contentious, what is not debated is
that proper resuscitation and warming
of the patient (and crucially, blood
products and fluids) is paramount to
the patients survival (9,13).
COMPLICATIONS
FOLLOWING
MAJOR HEPATIC INJURY
Whilst the major acute risk for these
patients is exsanguination, a large
proportion of deaths are attributable
to associated injuries incurred in the
accident, multi-organ failure, sepsis,
pneumonia and acute respiratory
distress (5,13). Late complications
include hepatic necrosis, bile duct
leakage, and intra-abdominal abscess.
MANAGEMENT
OF
INJURIES IN CHILDREN
HEPATIC
REFERENCES
1.
Pringle JH. Notes on the arrest of
hepatic haemorrhage due to trauma.
Ann Surg. 1908;48:541.
2.
Schrock T, Blaisdell FW, Mathewson C Jr. Management of blunt trauma
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DH. Selective Non-operative management of liver gunshot injuries. BJS.
2005;92:890-5.
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Ann Surg. 2000; 232: 324-30.
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Malhotra AK, Fabian AK, Croce
MA, Gavin TJ, Kudsk KA, Minard G et
al. Blunt hepatic injury: a paradigm
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2000;231:804-13.
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7.
Nicholas JM, Rix EP, Easley KA,
Felliciano DV, Cava RA, Ingram WL
et al. Changing patterns in the management of penetrating abdominal
trauma: the more things change, the
more they stay the same. J Trauma.
2002;55:1095-110.
8.
Hurtuk M, Reed RL 2nd, Esposito
TJ, Davis KA, Luchette FA. Trauma surgeons practice what they preach: the