Liver injury

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Liver injury
Extensive rupture of the liver Wellcome L0061656.jpg
A watercolour painting of a liver with extensive rupturing caused by blunt trauma to the abdomen.
Specialty Emergency medicine   OOjs UI icon edit-ltr-progressive.svg

A liver injury, also known as liver laceration, is some form of trauma sustained to the liver. This can occur through either a blunt force such as a car accident, or a penetrating foreign object such as a knife. [1] Liver injuries constitute 5% of all traumas, making it the most common abdominal injury. [2] Generally nonoperative management and observation is all that is required for a full recovery.

Contents

Cause

Given its anterior position in the abdominal cavity and its large size, the liver is prone to gun shot wounds and stab wounds. [2] Its firm location under the diaphragm also makes it especially prone to shearing forces. [1] Common causes of this type of injury are blunt force mechanisms such as motor vehicle accidents, falls, and sports injuries. Typically these blunt forces dissipate through and around the structure of the liver [3] and causes irreparable damage to the internal microarchitecture of the tissue. [4] With increasing velocity of the impact, the internal damage of the liver tissue also exemplifies[ clarification needed ] - even though the tissue itself is mechanically and micro-structurally isotropic. [5] A large majority of people who sustain this injury also have another accompanying injury. [1]

Diagnosis

Grade 4 liver laceration Grade4LiverLacMark.png
Grade 4 liver laceration
Isoliert intraparenchymatoese Leberruptur 24M - CT KM - 001.jpg

Imaging, such as the use of ultrasound or a computed tomography scan, is the generally preferred way of diagnosis as it is more accurate and is sensitive to bleeding, however; due to logistics this is not always possible. [6] For a person who is hemodynamically unstable a focused assessment with sonography for trauma (FAST) scan may take place which is used to find free floating fluid in the right upper quadrant and left lower quadrant of the abdomen. The FAST scan however may not be indicated in those who are obese and those with subcutaneous emphysema. [7] Its speed and sensitivity to injuries resulting in 400mL of free-floating fluid make it a valuable tool in the evaluation of unstable persons. Computed tomography is another diagnostic study which can be performed, but typically is only used in those who are hemodynamically stable. [7] A physical examination may be used but is typically inaccurate in blunt trauma, unlike in penetrating trauma where the trajectory the projectile took can be followed digitally. [8] A diagnostic peritoneal lavage (DPL) may also be utilized but has limited application as it is hard to determine the origin of the bleeding. [9] A diagnostic peritoneal lavage is generally discouraged when FAST is available as it is invasive and non-specific. [7]

Classification

Liver injuries are classified on a Roman numeral scale with I being the least severe, to V being the most severe, according to the AAST (American Association for the Surgery of Trauma) liver injury scale. [10]

The Liver Injury Scale classification (2018 revision) [1] [2] [10]
GradeSubcapsular hematomaLacerationVascular injury
I<10% surface area<1 cm in depth-
II10–50% surface area1–3 cm-
III>50% or >10 cm>3 cmAny injury in the presence of a liver vascular injury or active bleeding contained within liver parenchyma
IV25–75% of a hepatic lobeActive bleeding extending beyond the liver parenchyma into the peritoneum
V>75% of a hepatic lobeJuxtahepatic venous injury to include retrohepatic vena cava and central major hepatic veins

In the case of multiple liver injuries with different grades, the overall grade should be classified by the higher grade of injury. One grade should also be added in case of multiple injuries, up to grade III. [10]

Generally, any injury ≥III requires surgery. [3] [11]

Calculators have been developed that facilitate grading of liver injury based on imaging findings. [12]

Management

The initial management of liver trauma generally follows the same procedures for all traumas with a focus on maintaining airway, breathing, and circulation. A physical examination is a cornerstone of the assessment of which there are various non-invasive means of diagnostic tools that can be utilized. [3] An invasive diagnostic peritoneal lavage can also be used to diagnose and classify the extent of the damage. [13] [14] A large majority of liver injuries are minor and require only observation. [15] Generally if there is estimated to be less than 300mL of free floating fluid, no injury to surrounding organs, and no need for blood transfusion, there is a low risk of complication from nonoperative management. [1] In special cases where there is a higher risk with surgery, such as in the elderly, nonoperative management would include the infusion of packed red blood cells in an intensive care unit. [2] Typically hepatic injuries resulting from stab wounds cause little damage unless a vital part of the liver is injured, such as the hepatic portal vein; with gunshot wounds, the damage is worse. [16]

Surgery

In severe liver injuries (class ≥III), or those with hemodynamic instability, surgery is generally necessary. [7] Surgical techniques such as perihepatic packing or the use of the Pringle manoeuvre can be used to control hemorrhage. [2] [3] Temporary control of the hemorrhage can be accomplished through direct manual pressure to the wound site. [2] In these severe cases it is important to prevent the progression of the trauma triad of death, which often requires the utilization of damage control surgery. [14] New devices are being developed in order to control the bleeding using negative pressure. [17]

The common cause of death while operating is exsanguination caused by profuse loss of blood volume. [18] Rarely, surgery entails the use of liver resection, which removes the source of the bleeding and necrotic tissue. The drastic nature of this procedure means it can only be used in hemodynamically stable patients. [11] Another rare procedure would be liver transplantation which is typically impractical due to the logistics of finding a proper organ donor in a timely fashion. [19]

History

In the 1880s a severe liver injury would in most cases prove fatal in the first 24 hours after sustaining the injury. [20] Before the 1980s nonoperative management was seldom used in favor of the methods of management suggested by James Hogarth Pringle. [21] [22] During World War II the use of early laparotomy was popularized and in conjunction with the use of transfusions, advanced anesthetics, and other new surgical techniques led to decreased mortality. [23]

Related Research Articles

<span class="mw-page-title-main">Peritonitis</span> Inflammation of the inner wall of the abdomen (peritoneum)

Peritonitis is inflammation of the localized or generalized peritoneum, the lining of the inner wall of the abdomen and cover of the abdominal organs. Symptoms may include severe pain, swelling of the abdomen, fever, or weight loss. One part or the entire abdomen may be tender. Complications may include shock and acute respiratory distress syndrome.

<span class="mw-page-title-main">Injury in humans</span> Physiological wound caused by an external source

An injury is any physiological damage to living tissue caused by immediate physical stress. Injuries to humans can occur intentionally or unintentionally and may be caused by blunt trauma, penetrating trauma, burning, toxic exposure, asphyxiation, or overexertion. Injuries can occur in any part of the body, and different symptoms are associated with different injuries.

<span class="mw-page-title-main">Major trauma</span> Injury that could cause prolonged disability or death

Major trauma is any injury that has the potential to cause prolonged disability or death. There are many causes of major trauma, blunt and penetrating, including falls, motor vehicle collisions, stabbing wounds, and gunshot wounds. Depending on the severity of injury, quickness of management, and transportation to an appropriate medical facility may be necessary to prevent loss of life or limb. The initial assessment is critical, and involves a physical evaluation and also may include the use of imaging tools to determine the types of injuries accurately and to formulate a course of treatment.

<span class="mw-page-title-main">Splenic injury</span> Injury to the spleen

A splenic injury, which includes a ruptured spleen, is any injury to the spleen. The rupture of a normal spleen can be caused by trauma, such as a traffic collision.

Autotransplantation is the transplantation of organs, tissues, or even particular proteins from one part of the body to another in the same person.

<span class="mw-page-title-main">Blunt trauma</span> Trauma to the body without penetration of the skin

Blunt trauma, also known as blunt force trauma or non-penetrating trauma, describes a physical trauma due to a forceful impact without penetration of the body's surface. Blunt trauma stands in contrast with penetrating trauma, which occurs when an object pierces the skin, enters body tissue, and creates an open wound. Blunt trauma occurs due to direct physical trauma or impactful force to a body part. Such incidents often occur with road traffic collisions, assaults, and sports-related injuries, and are notably common among the elderly who experience falls.

<span class="mw-page-title-main">Pelvic fracture</span> Broken bone in nonacetabular portions of pelvis

A pelvic fracture is a break of the bony structure of the pelvis. This includes any break of the sacrum, hip bones, or tailbone. Symptoms include pain, particularly with movement. Complications may include internal bleeding, injury to the bladder, or vaginal trauma.

<span class="mw-page-title-main">Focused assessment with sonography for trauma</span> Fluid accumulation screening

Focused assessment with sonography in trauma is a rapid bedside ultrasound examination performed by surgeons, emergency physicians, and paramedics as a screening test for blood around the heart or abdominal organs (hemoperitoneum) after trauma. There is also the extended FAST (eFAST) which includes some additional ultrasound views to assess for pneumothorax.

Hemoperitoneum is the presence of blood in the peritoneal cavity. The blood accumulates in the space between the inner lining of the abdominal wall and the internal abdominal organs. Hemoperitoneum is generally classified as a surgical emergency; in most cases, urgent laparotomy is needed to identify and control the source of the bleeding. In selected cases, careful observation may be permissible. The abdominal cavity is highly distensible and may easily hold greater than five liters of blood, or more than the entire circulating blood volume for an average-sized individual. Therefore, large-scale or rapid blood loss into the abdomen will reliably induce hemorrhagic shock and, if untreated, may rapidly lead to death.

Diagnostic peritoneal lavage (DPL) or diagnostic peritoneal aspiration (DPA) is a surgical diagnostic procedure to determine if there is free floating fluid in the abdominal cavity.

<span class="mw-page-title-main">Gunshot wound</span> Injury caused by a bullet

A gunshot wound (GSW) is a penetrating injury caused by a projectile from a gun. Damage may include bleeding, bone fractures, organ damage, wound infection, loss of the ability to move part of the body, and in severe cases, death. Damage depends on the part of the body hit, the path the bullet follows through the body, and the type and speed of the bullet. Long-term complications can include bowel obstruction, failure to thrive, neurogenic bladder and paralysis, recurrent cardiorespiratory distress and pneumothorax, hypoxic brain injury leading to early dementia, amputations, chronic pain and pain with light touch (hyperalgesia), deep venous thrombosis with pulmonary embolus, limb swelling and debility, and lead poisoning.

<span class="mw-page-title-main">Penetrating trauma</span> Type of injury

Penetrating trauma is an open wound injury that occurs when an object pierces the skin and enters a tissue of the body, creating a deep but relatively narrow entry wound. In contrast, a blunt or non-penetrating trauma may have some deep damage, but the overlying skin is not necessarily broken and the wound is still closed to the outside environment. The penetrating object may remain in the tissues, come back out the path it entered, or pass through the full thickness of the tissues and exit from another area.

<span class="mw-page-title-main">Abdominal trauma</span> Medical condition

Abdominal trauma is an injury to the abdomen. Signs and symptoms include abdominal pain, tenderness, rigidity, and bruising of the external abdomen. Complications may include blood loss and infection.

<span class="mw-page-title-main">Diaphragmatic rupture</span> Tear in the thoracic diaphragm

Diaphragmatic rupture is a tear of the diaphragm, the muscle across the bottom of the ribcage that plays a crucial role in breathing. Most commonly, acquired diaphragmatic tears result from physical trauma. Diaphragmatic rupture can result from blunt or penetrating trauma and occurs in about 0.5% of all people with trauma.

Perihepatic packing is a surgical procedure used in connection with trauma surgery to the liver. In this procedure the liver is packed to stop non arterial bleeding, most often caused by liver injury.

An exploratory laparotomy is a general surgical operation where the abdomen is opened and the abdominal organs are examined for injury or disease. It is the standard of care in various blunt and penetrating trauma situations in which there may be life-threatening internal injuries. It is also used in certain diagnostic situations, in which the operation is undertaken in search of a unifying cause for multiple signs and symptoms of disease, and in the staging of some cancers.

<span class="mw-page-title-main">Stab wound</span> Medical condition

A stab wound is a specific form of penetrating trauma to the skin that results from a knife or a similar pointed object. While stab wounds are typically known to be caused by knives, they can also occur from a variety of implements, including broken bottles and ice picks. Most stabbings occur because of intentional violence or through self-infliction. The treatment is dependent on many different variables such as the anatomical location and the severity of the injury. Even though stab wounds are inflicted at a much greater rate than gunshot wounds, they account for less than 10% of all penetrating trauma deaths.

A pancreatic injury is some form of trauma sustained by the pancreas. The injury can be sustained through either blunt forces, such as a motor vehicle accident, or penetrative forces, such as that of a gunshot wound. The pancreas is one of the least commonly injured organs in abdominal trauma.

An atriocaval shunt (ACS) is an intraoperative surgical shunt between the atrium of the heart and the inferior vena cava. It is used during the repair of larger juxtahepatic vascular injuries such as an injury to the local vena cava. Injuries to the inferior vena cava are challenging, those behind the liver being the most difficult to repair.

Endovascular and hybrid trauma and bleeding management is a new and rapidly evolving concept within medical healthcare and endovascular resuscitation. It involves early multidisciplinary evaluation and management of hemodynamically unstable patients with traumatic injuries as well as being a bridge to definitive treatment. It has recently been shown that the EVTM concept may also be applied to non-traumatic hemodynamically unstable patients.

References

  1. 1 2 3 4 5 Piper GL, Peitzman AB (August 2010). "Current management of hepatic trauma". The Surgical Clinics of North America. 90 (4): 775–85. doi:10.1016/j.suc.2010.04.009. PMID   20637947.
  2. 1 2 3 4 5 6 Cothren CC, Moore EE (August 2008). "Hepatic Trauma". European Journal of Trauma and Emergency Surgery. 34 (4): 339–54. doi:10.1007/s00068-008-8029-5. PMID   26815811. S2CID   22788477.
  3. 1 2 3 4 Bouras AF, Truant S, Pruvot FR (December 2010). "Management of blunt hepatic trauma". Journal of Visceral Surgery. 147 (6): e351-8. doi: 10.1016/j.jviscsurg.2010.10.004 . PMID   21111696.
  4. ↑ Chen J, Brazile B, Prabhu R, Patnaik SS, Bertucci R, Rhee H, Horstemeyer MF, Hong Y, Williams LN, Liao J (July 2018). "Quantitative Analysis of Tissue Damage Evolution in Porcine Liver With Interrupted Mechanical Testing Under Tension, Compression, and Shear". Journal of Biomechanical Engineering. 140 (7): 0710101–07101010. doi:10.1115/1.4039825. PMC   5938066 . PMID   29715364.
  5. ↑ Williams, Lakiesha N.; Liao, Jun; Horstemeyer, Mark F.; Marin, Esteban; Bouvard, Jean-Luc; Priddy, Lauren B.; Prabhu, R. K.; Patnaik, Sourav S.; Chen, Joseph (June 2019). "Mechanical Response of Porcine Liver Tissue under High Strain Rate Compression". Bioengineering. 6 (2): 49. doi: 10.3390/bioengineering6020049 . PMC   6630843 . PMID   31151177.
  6. ↑ Moore 2012, p. 543
  7. 1 2 3 4 Coccolini F, Montori G, Catena F, Di Saverio S, Biffl W, Moore EE, Peitzman AB, Rizoli S, Tugnoli G, Sartelli M, Manfredi R, Ansaloni L (2015-01-01). "Liver trauma: WSES position paper". World Journal of Emergency Surgery. 10: 39. doi: 10.1186/s13017-015-0030-9 . PMC   4548919 . PMID   26309445.
  8. ↑ Pietzman 2002, p. 255
  9. ↑ Moore 2012, p. 542
  10. 1 2 3 "Injury Scoring Scale". The American Association for the Surgery of Trauma. 2009-08-27. Retrieved 2023-11-03.
  11. 1 2 Krawczyk M, Arkuszewski P (2009). "Surgical Management of Liver Trauma". Polish Journal of Surgery. 81 (11): 554. doi: 10.2478/v10035-009-0090-1 . S2CID   12453253.
  12. ↑ "Liver Trauma Injury Score Calculator". Rad At Hand. Retrieved 2024-07-11.
  13. ↑ Moore 2012, p. 541
  14. 1 2 Stracieri LD, Scarpelini S (2006). "Hepatic injury". Acta Cirurgica Brasileira. 21 (Suppl 1): 85–8. doi: 10.1590/s0102-86502006000700019 . PMID   17013521.
  15. ↑ American College of Surgeons (2004). Atls, Advanced Trauma Life Support Program for Doctors . Amer College of Surgeons. ISBN   978-1-880696-14-9.
  16. ↑ Kenneth D. Boffard (2007). Manual of definitive surgical trauma care . London: Hodder Arnold. pp.  108. ISBN   978-0-340-94764-7.
  17. ↑ Segura-Sampedro, Juan José; Pineño-Flores, Cristina; Craus-Miguel, Andrea; Morales-Soriano, Rafael; González-Argente, Francesc Xavier (2019-12-16). "New hemostatic device for grade IV–V liver injury in porcine model: a proof of concept". World Journal of Emergency Surgery. 14 (1): 58. doi: 10.1186/s13017-019-0277-7 . ISSN   1749-7922. PMC   6916102 . PMID   31889989.
  18. ↑ Ahmed I, Beckingham IJ (2007). "Liver trauma". Trauma. 9 (3): 171–180. doi:10.1177/1460408607086775. S2CID   208270204.
  19. ↑ Parks RW, Chrysos E, Diamond T (September 1999). "Management of liver trauma". The British Journal of Surgery. 86 (9): 1121–35. doi: 10.1046/j.1365-2168.1999.01210.x . PMID   10504364. S2CID   40857849.
  20. ↑ Moynihan BB (1906). Abdominal operations. Saunders. p. 563. Retrieved 2012-08-04.
  21. ↑ Pringle JH (October 1908). "V. Notes on the Arrest of Hepatic Hemorrhage Due to Trauma". Annals of Surgery. 48 (4): 541–9. doi:10.1097/00000658-190810000-00005. PMC   1406963 . PMID   17862242.
  22. ↑ Feliciano DV, Rozycki GS (2002). "Hepatic trauma". Scandinavian Journal of Surgery. 91 (1): 72–9. doi: 10.1177/145749690209100112 . PMID   12075841.
  23. ↑ Moore 2012, p. 539

Bibliography

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