Liver injury

Background

• Occurs in 5% of all traumas
  • Most common abdominal injury

Clinical Features

• RUQ pain

Differential Diagnosis

Abdominal Trauma

• Abdominal compartment syndrome
• Diaphragmatic trauma
• Duodenal hematoma
• Genitourinary trauma
• Liver trauma
• Pelvic fractures
  • Acetabular pelvic fractures
  • Open book pelvic fracture
  • Straddle pelvic fracture
  • Pelvic avulsion fracture
• Retroperitoneal hemorrhage
• Renal trauma
• Splenic trauma
• Trauma in pregnancy
• Ureter trauma

Evaluation

ATLS Blunt Abdominal Trauma Algorithm

• Unstable
  • FAST to search for free fluid (vs. DPL if unavailable)
    • Positive: Exploratory laparotomy
    • Negative: CT scan
• Stable
  • CT scan
    • Exploratory laparotomy, angiographic embolization, conservative management as indicated

American Association for the Surgery of Trauma Grading System

The Liver Injury Scale classification

Grade	Hematoma	Laceration
I	Subcapsular, <10% surface area	capsular tear, <1 cm in depth
II	10–50% surface area	1–3 cm
III	>50% or >10 cm	>3 cm
IV	25–75% of a hepatic lobe
V	>75% of a hepatic lobe
VI	Hepatic avulsion

Liver injuries are classified on a Roman numeral scale with I being the least severe, to VI being the most severe. Generally any injury ≥III requires surgery.

Grade 4 liver laceration (arrow).

• grade I

• grade II
  • hematoma: subcapsular, 10-50% surface area
  • hematoma: intraparenchymal <10 cm diameter
  • laceration: capsular tear, 1-3 cm depth, <10 cm length
• grade III
  • hematoma: subcapsular, >50% surface area, or ruptured with active bleeding
  • hematoma: intraparenchymal >10 cm diameter
  • laceration: capsular tear, >3 cm depth
• grade IV
  • hematoma: ruptured intraparenchymal with active bleeding
  • laceration: parenchymal disruption involving 25-75% hepatic lobe or involves 1-3 Couinaud segments (within one lobe)
• grade V
  • laceration: parenchymal disruption involving >75% of hepatic lobe or involves >3 Couinaud segments (within one lobe)
  • vascular: juxtahepatic venous injuries (inferior vena cava, major hepatic vein)
• grade VI
  • vascular: hepatic avulsion

Advance one grade for multiple injuries up to grade III

Management

• Nonoperative management is successful in >90% of patients who are hemodynamically stable
• Low-grade injuries (grades I–III) can almost always be managed without surgery
  • Higher-grade injuries commonly fail nonoperative therapy.
• Consider angiographic embolization if:
  • Large amount of hemoperitoneum
  • Vascular injury (contrast blush) on CT

Disposition

• Typically admission via OR, IR, or floor/ICU for conservative management

See Also

• Abdominal Trauma
• Trauma in Pregnancy