1. Liver Trauma

2. Background Largest solid abdominal organ,fixed position
Second most common injured, but most common cause of death after abdominal trauma
Blunt MVA most common
80% adults, 97% children-conservative rx

3. Pathophysiology
Friable parenchyma, thin capsule, fixed position in relation to spine.
Right lobe gets hit more since its larger, and closer to ribs.
85% injuries involve segments 6,7,8 from compressioin against ribs, spine, abd wall.
Shear forces at attachments to diaphragm
Transmission thru right hemithorax.

4. Pathophysiology
Liver injured easily in children since ribs are compliant, force transmitted.
Liver not as developed in children, with weaker connective tissue framework.
Iatrogenic injuries by biopsies, biliary drainage, TIPS, can cause capsular tears and bile leaks, fistulas, hemoperitoneum.

5. Injuries Subcapsular hematoma or intrahepatic hematoma. Laceration
Contusion
Hepatic vascular disruption
Bile duct injury
86% of injuries have stopped bleeding at time of exploration.
Decreased transfusion req.With conservative.

6. Injuries
Mild hepatic injuries involving < 25% of one lobe heal in 3 mos.
Moderate injuries involving 25-50% of one lobe heal in 6 mos.
Sever injuries require 9-15 mos to heal.
Gallbladder injuries rare, with contusons being most common, avulsions next most.

7. Anatomy
Cantile described main divisions along a main plane from GB fossa to IVC. Divides liver into equal halves.
Couinaud developed 4 sectors and 8 segments, divided into vertical and oblique planes, defined by the 3 main hepatic veins and transverse plane thru right and left portal branches.

8. Anatomy Hepatic veins lie between segments.
Left hepatc vein divides left lobe into medial and lateral segments.
Middle hepatic vein divides liver into left and right lobes.

9. Anatomy
Right hepatic vein divides right lobe into anterior and posterior segments.
A horizontal line thru left and right main portal veins is used to divide lobes into inferior and superior segments.
The 8 liver segments are numbers clockwise on the frontal view.

10. Liver Segments

11. Liver Segments

12. Clinical Details
Symptoms of injury are related to blood loss, peritoneal irritation, RUQ tenderness, and guarding.
Unrecognized delayed abcess
Bilomas
Signs of blood loss may dominate the picture.

13. Clinical Details Elevated liver tests
Biliary peritonitis (nausea, vomiting, abd pain).
DPL has high sensitivity, 1-2% complication rate.
Plain x-rays non-specific.
CT scan diagnostic procedure of choice.
Hida for leaks, angio for hemorrhage.

14. Limitations
FAST sensitivity highest (98%) for grade 3 injuries or greater. Negative findings do not exclude hepatic injury.
Emergency sono findings demonstrating free fluid, parenchymal injury, or both demonstrate overall sensitivity for detection of blunt abdominal trauma of 72%.
Angiogram may fail to detect active bleeding.

15. CT Scans
Accurate in localizing the site of liver injury, associated injuries.
Used to monitor healing.
CT criteria for staging liver trauma uses AAST liver injury scale
Grades 1-6
Hematoma,laceration,vascular,acute bleeding,gallbladder injury,biloma.

16. Classification
I-Subcapsular hematoma<1cm, superficial laceration<1cm deep.
II-Parenchymal laceration 1-3cm deep, subcapsular hematoma1-3 cm thick.
III-Parenchymal laceration> 3cm deep and subcapsular hematoma> 3cm diameter.

17. Classification
IV-Parenchymal/supcapsular hematoma> 10cm in diameter, lobar destruction, or devasularization.
V- Global destruction or devascularization of the liver.
VI-Hepatic avulsion

18. Angiography Demonstrates active bleeding
Transcatheter embolization may be the only treatment required.
Findings include contusion, laceration, hematoma, pseudoaneurysms, fistulas.
Embolization can reduce transfusion requirements, stenting for fistulas.

19. Angiography

20. Grade I Liver Injury

21. Grade II Liver Injury

22. Grade III

23. Grade IV

24. Grade V