A case presentation of a patient with liver trauma and literature review at the end

1. Traumatic Liver Injuries
By
Dr. Monsif Iqbal
Surgical Unit II

2. CASE PRESENTATION

3. PATIENT’s PROFILE:
• Name: XYZ
• Age: 17 yrs.
• Sex: Male
• Address : Wah Cantt.
• D.O.A: 18-04-2011
• M.O.A: ER

4. PRESENTING COMPLAINTS
• H/O RTA, Patient while on motor bike struck
against the concrete block of an electric pole –
2 hrs
• Sustaining injury to the lower chest and
abdomen
• Complain of severe chest and abdominal pain
• 2 episodes of Vomiting
• Drowsiness

5. PHYSICAL EXAMINATION:
On Examination
» Pulse: 103/min
» B.P: 84/60 mm of Hg
» Oxygen Sat: 99%
» GCS 15/15
» Abrasions right lower chest and epigastrium
On Abdominal Examination
– sever tender epigastrium
– mild generalized tenderness

6. INVESTIGATIONS:
1. Blood CP:
• Hb ---- 11.3 gm/dl
• TLC ---- 24.6x103/ul
• PLT ---- 434x103/ul
2. ALT: 57
3. RFTs: Urea: 34, Creatinine 0.75
sodium : 139
Potassium : 4.0
Chloride : 101

7. Management
• 2 large bore IV lines
• IV fluids rushed
• IV antibiotics and Analgesics started
• Blood sample sent for grouping and cross matching
• Patient shifted to ITC, there B.P. 70/45mmHg, Pulse 125/min
• USG FAST carried out
– Gross intraperitoneal fluid collection
– Left lobe of the liver ---- ill defined
– Suspicion of liver injury

8. Management (cont.)
• Patient shifted to OT and urgent exploratory
lapratomy carried out, the findings were
– Laceration of the left lobe of the liver
– Massive blood in the peritoneum
– A 3 cm perforation in the left hemidiaphram
• Left lobectomy, bleeding vessels underun,
perihepatic packing, perfortion in the diaphram
sealed, drain put in RUQ, abdomen partially
closed, and left sided chest intubation done
• 3 units of blood transfused peroperatively

9. Management (cont.)
• After 48 hours, the pateint was shifted again to
OT, abdomen opened, perihepatic packs
removed, no active bleeding, hemotama around
the raw area,,,, the abdomen was closed in the
layers and the drain remained there…
• The patient weaned off the ventilator support
after 48 hours,the recovery uneventful, drain
output NIL and removed at 7th day
posoperatively..

12. Traumatic Liver Injuries

13. Anatomy

15. Segmental Anatomy

16. Clinical Presentation
• Histroy
• RTA
• Fall
• Penetrating injuries
• Clinical Findings:
• Bruises on the epigastrium or entry wound
• Tachycardia
• Tachypnea
• Shock

17. Diagnostic Modalities
• DPL
--fast, sensitive, accurate and simple to perform
--invasive, cannot diagnose retroperitoneal injury
--DPL is positive when
-more than 10 ml of frank blood in the aspirated fluid
-fecal matter or bile
- >100,000 RBC/micL
- >500 WBC/micL
• X-ray
--nonspecific, but useful in showing the extent of associated skeletal
trauma
• Ultrasonography (FAST)
--fast, accurate, noninvasive, a good initial screening test
--sensitivity 88%, specificity 99%, accuracy 97%

18. Ultrosonography

19. • CT Scan
– The standard evaluation method for stable pt
– Performed with water soluble oral and
intravenous contrast

22. Management Algorithm

23. American Association for the surgery of trauma organ injury scale
:liver
*Advance one grade for multiple injuries, up to grade III.

24. Management according to the Grade
• Grade I,II
---minor injuries, represent 80-90% of all
injuries, require minimal or no operative
treatment
• Grade III-V
-- severe,require surgical intervention
• Grade VI
--incompatible with survival

25. Non Operative Management
• Criteria
--hemodynamically stable
--absence of active hemorrhage
--hemoperitoneum of less than 500ml
--absence of peritoneal sign
--absence of other peritoneal injuries that
would otherwise require an operation

26. Non Operative Management
• Criteria (continued)
--good quality CT scans
--experienced radiologist
--intensive care setting
• Currently believe that ultimate decisive factor
should be the hemodynamic stability at
presentation or after initial resuscitation,
irrespective of the grade of injury on CT or the
amount of hemoperitoneum

27. Non Operative Management
• Complications
--Delayed hemorrhage
‧ most common, usual indication for a delayed
operation
‧under strict guidelines, the incidence ranges
from 0-5%, and blood transfusions are
required in fewer than 20%
‧ common errors:
(1)assuming that the hemorrhage is
not related to the liver
(2)multiple(more than
four)blood transfusions in the hope that it will stop
(3)misreading CT and underestimating
hemoperitoneum and active bleeding

28. Non-operative management

29. • Complications
--biliary fistula and liver abscess
‧ranges from 0.5-20
‧nasobilaiary or percutaneous tranhepatic drainage or
endoprothesis insertion
. If fails, then needs surgical resection of affected segment
--Hemobilia
‧1%, iatrogenic causes most common
‧injury causes communication between the
biliary tract and blood vessels
‧abdominal trauma, jaundice, RUQ colicky pain and blood
in vomitus or stool point to this diagnosis
‧managed by percutaneous selective hepatic a.
embolization or surgical intervention

30. • Complications
--bilihemia
‧rare complication of severe decelerationon injury, in which the
hepatic venules and the intrahepatic bile ducts rupture
‧excessive bilirubin level
‧endoscopic sphincterotomy and biliary
endostenting
--Extrahepatic bile duct stricture
‧ Endobiliary ballon dilatation or stenting
‧ usually require surgical correction using Roux-en-Y
hepatodochojejunostomy
• Mortality rate
--7-13% with most resulting from associated injuries
--0-0.4% resulting from liver itself

31. Operative interventions

32. Operative interventions
• Initial control of bleeding achieved with
temporary tamponade using packs, portal
triad occlusion(Pringle manoeuvre), bimanual
compression of the liver or even manual
compression abdominal aorta above celiac
trunk
• If hemorrhage is unaffected by portal triad
occlusion(Pringle manoeuvre) by digital
compression or vascular clamp, major vena
cava injury or atypical vascular anatomy
should be expected

33. Operative interventions (cont.)
Perihepatic packing
--Indication:coagulopathy, irreversible shock from
blood loss (10u), hypothermia(32C), acidosis(PH7.2),
bilobar injury,large nonexpanding hematoma,
capsular avulsion, vena cava or hepatic vein injuries

34. Perihepatic packing

35. Operative interventions (cont.)
• Hepatotomy with direct suture ligation
--using the finger fracture technique,
electrocautery or an ultrasonic dissector to
expose damaged vessels and hepatic duct
which ligated , clipped or repaired
--low incidence of rebleeding, necrosis and
sepsis
--effectives following blunt liver trauma
requires further evaluation

36. Operative interventions (cont.)
• Resection debridement
--removal devitalized tissue
--rapid compared with standard anatomical
resection, which are more time consuming
and remove more normal liver parenchyma
--reduced risk of post-op sepsis secondary
hemorrhage and bile leakage

37. Operative interventions (cont.)
• Mesh rapping
--new technique for grade III,IV laceration,
tamponading large intrahepatic hematomas
--not indicated where juxtacaval or hepatic vein
injury is suspected
• Anatomical resection
--reserved for deep laceration involving major
vessels or bile ducts, extensive devascularization
and major hepatic venous bleeding

38. Mesh rapping

39. Other Operative interventions
• Omental packing
• Intrahepatic tamponade with penrose drains
• Fibrin glue
• Retrohepatic venous injuries
--Complete Vascular isolation of the liver
--venovenous bypass
--Atriocaval shunting
• Liver transplantation

40. Operative management
• Complications
--Hemorrhage,sepsis
--Biliary fistula
--Respiratory problems
--Liver failure
--Hyperpyrexia
--Acalculous cholecystitis
--Pancreatic, duodenal or small bowel fistula

41. THANKS