Saudi Surgical Journal

REVIEW ARTICLE
Year
: 2017  |  Volume : 5  |  Issue : 2  |  Page : 53--59

Diagnosis and treatment of traumatic liver injuries


Bilal O Al-Jiffry 
 Department of Surgery, College of Medicine and Medical Sciences, Taif University, PO Box 888, Taif 21947, Kingdom of Saudi Arabia

Correspondence Address:
Bilal O Al-Jiffry
Department of Surgery, College of Medicine and Medical Sciences, Taif University, PO Box 888, Taif 21947
Kingdom of Saudi Arabia

Abstract

Following abdominal trauma, especially the blunt one, the liver is considered the second abdominal organ liable to injury and the first leading cause of death. The most common cause of liver injury is blunt abdominal trauma secondary to motor vehicle accidents and it carries a higher mortality rate than open one. With the recent trends of nonoperative management of the majority of liver trauma patients, the introduction of damage control surgery (DCS) and other therapies such as hepatic artery embolization and liver transplantation is still having a growing role in severe hepatic injuries with hemodynamic instability. The better understanding of hepatic anatomy and pathophysiology, in addition to the advance in diagnostic imaging, resuscitation, intensive care, and the introduction of DCS, has led to marked improvement in the mortality rate following liver injury.



How to cite this article:
Al-Jiffry BO. Diagnosis and treatment of traumatic liver injuries.Saudi Surg J 2017;5:53-59


How to cite this URL:
Al-Jiffry BO. Diagnosis and treatment of traumatic liver injuries. Saudi Surg J [serial online] 2017 [cited 2020 Feb 26 ];5:53-59
Available from: http://www.saudisurgj.org/text.asp?2017/5/2/53/211610


Full Text

 Introduction



The liver is the largest intra-abdominal solid organ with a thin capsule and a relatively fixed position in relation to the spine, making it particularly prone to injury and it is the second most commonly injured organ in abdominal trauma, but damage to the liver is the most common cause of death after abdominal injury.[1],[2],[3] The right hemi liver is injured more commonly than the left due to its large size and proximity to ribs.[1] In Europe, blunt trauma accounts for 80%–90% of all liver injuries, while in South Africa and North America, penetrating injuries account for 66% and 88% of liver trauma, respectively.[1] The mortality rate is higher with blunt abdominal trauma than with penetrating injuries.[4]

The initial clinical assessment of patients with blunt abdominal trauma is often inaccurate as the associated injuries often cause tenderness and spasms in the abdominal wall and make diagnosis difficult; however, the diagnostic accuracy has been improved due to the advancement in imaging modalities.[1],[2],[3],[4],[5]

Management of liver trauma may vary widely from nonoperative management (NOM) with or without angioembolization to damage control surgery (DCS) which is mainly centered on stopping the bleeding by packing, Pringle's maneuver, and vascular exclusion to totally replacing the liver by a liver transplant.[4],[5],[6] In this article, the different options of diagnosis and treatment of liver trauma will be discussed.

 Diagnosis



Clinical manifestations of hepatic injuries are related to the type of trauma, amount of blood loss, and peritoneal irritation.[7],[8],[9] There would be a history of blunt or penetrating trauma with pain in the right upper abdominal quadrant which may be referred to the right shoulder due to irritation of the inferior surface of the diaphragm in addition to nausea and vomiting.[1],[2],[3] Examination of the patient will show variable degrees of shock which may predominate the picture.[9] Signs of peritoneal irritation such as tenderness, rebound tenderness, and guarding are usually found and these signs would be prominent in case of bile leak.[8] The initial clinical assessment of patients with blunt abdominal trauma is often inaccurate as the associated injuries often cause tenderness and spasms in the abdominal wall and make diagnosis difficult.[1] Studies showed that the accuracy rate of clinical evaluation alone does not exceed 65% for detecting intraperitoneal bleeding.[8] Occasionally, patients with blunt abdominal trauma do well initially, but they subsequently develop a liver abscess, presumably due to unrecognized liver damage and these patients present with signs and symptoms of deep-seated infection.[9] The mechanism of injury is critically important in assessing patients with abdominal injury and this information may be obtained from the patient, relatives, police, or emergency care personnel.[10] Following initial assessment, a conscious patient, who is hemodynamically unstable following blunt trauma and has generalized peritonism, or those with sustained penetrating injury, should undergo immediate laparotomy without further investigation.[10],[11],[12],[13]

Hemodynamically stable patients with suspected liver injury can be investigated at this stage to define the nature of the injury.[10] Focused assessment with sonography for trauma (FAST) has gained increased acceptance, particularly in the emergency department, for the rapid evaluation of patients with blunt or penetrating abdominal trauma.[14],[15],[16],[17],[18],[19] It is cheap, portable, and noninvasive, compared to peritoneal lavage, and it does not use radiation or iodinated contrast media.[20],[21],[22] The sensitivity of FAST for the presence of intra-abdominal fluid in patients with trauma ranges from 75% to 93.8% and the specificity from 97% to 100%.[14],[15] However, some pitfalls remain in abdominal ultrasonography such as missing injuries at the dome or lateral segments of the liver and difficulty in distinguishing hepatic lacerations or hematomas because they are isoechoic to the normal liver.[23],[24] Contrast-enhanced ultrasonography has been proved to be useful in penetrating liver trauma without prolongation of examination time and it increases the sensitivity and the specificity of ultrasound in the evaluation of abdominal trauma not only in the detection of free peritoneal fluid but also in the visualization of the parenchymal lacerations.[25] However, US is operator dependent, where you may not find an expert ultrasonographer in the midnight; in addition, US contrast is not widely available in every casualty.[1]

Contrast-enhanced computed tomography (CT) is the gold standard diagnostic tool as it has high sensitivity and specificity for detecting liver injuries which increase as the time between injury and scanning increases, evidently because hematomas and lacerations become better defined.[9],[26],[27],[28],[29] CT without intravenous contrast enhancement is of limited value in hepatic trauma, but it can be useful in identifying or following up a hemoperitoneum.[18],[30],[31] The advantages of CT scanning in hepatic injury include the following; accurate grading of liver injuries, crude quantitation of the degree of hemoperitoneum, mandatory for patients with blunt trauma whose liver injury is to be managed nonoperatively, and detection of missile tracts in penetrating trauma patients which is imperative for surgeons who want to attempt nonoperative management of penetrating wounds.[32],[33],[34],[35] Although CT is very useful in the evaluation of stable patients with abdominal trauma, most authors agree that unstable patients, with either blunt or penetrating trauma, are unlikely to benefit from this investigation because of the valuable time that it requires.[32] False-positive errors are recorded with CT scans where the adjacent ribs may mimic contusion or hematoma, especially in the presence of air contrast level within the stomach in a patient with a nasogastric tube.[36],[37] False-negative findings may occur if contrast enhancement is used in patients with fatty liver where the enhanced fatty liver may become iso-attenuating relative to the laceration or hematoma; in this situation, a nonenhanced CT scan may provide useful information regarding hepatic injury.[37] Branching hepatic lacerations can mimic unopacified portal or hepatic veins or dilated intrahepatic bile ducts, so careful evaluation of serial images has to be done.[36],[37]

Magnetic resonance imaging (MRI) has a limited role in the evaluation of blunt abdominal trauma, it has no advantage over CT scanning, and there is no sufficient experience to establish its false-positive and false-negative findings.[6] However, MRI may be useful in pregnant women in whom the radiation dose is a concern, in patients with renal failure, and in allergic patients to radiographic contrast medium, in addition, magnetic resonance cholangiopancreatography (MRCP) can be used in the assessment of biliary injury including that of pancreatic duct trauma.[38]

Angiography can be used in stable patients where cross-sectional imaging may provide sufficient detail to treat the patient conservatively; however, it has no role in unstable patients.[39] A dynamic angiographic study may demonstrate the site of active bleeding; in addition, it can be combined with angiographic embolization, especially in high-grade liver injury.[40]

Endoscopic retrograde cholangiopancreatography (ERCP) may help in the delineation of the biliary tree in patients with liver trauma, and stents may be used to treat biliary leaks.[41],[42]

Laparoscopy in patients with abdominal trauma can reduce negative and nontherapeutic laparotomy rates, patient morbidity rates, hospital treatment costs, and can be used as therapeutic tool in selected patients; however, its use in this context requires further study.[43],[44],[45],[46],[47],[48],[49],[50]

 Classification of Liver Injury



Liver trauma ranges from a minor capsular tear, with or without parenchymal injury, to extensive disruption involving both hemi liver with associated hepatic vein or vena caval injury.[1] In 1989, the Organ Injury Scaling Committee of the American Association for the Surgery of Trauma produced a Hepatic Injury Scale and it was revised and modified in 1994[51] by which hepatic injuries are described in most major trauma centers [Table 1]. Grade I or II injuries are considered minor; they represent 80%–90% of all cases and usually require minimal or no operative treatment.[1],[52] Grade III–V injuries are generally considered severe and often require surgical intervention, while Grade VI injuries are regarded as incompatible with survival.[1]{Table 1}

 Management



Nonoperative

Three observations prompted the move toward nonoperative treatment. First, the practice of nonoperative treatment was initially advocated for splenic injuries and then extended to the liver. The success of treatment in children led to attempts of nonoperative treatment in adults.[52],[53],[54] Second, the high rate of nontherapeutic operations in many patients with blunt hepatic injuries was not in patients' best interest.[1] Third, the advent of CT scanning greatly facilitated both diagnosis and grading of injuries and gave some reassurance that the intestinal injuries had not occurred.[1],[54]

There has been several reports started since 1985, where Trunkey [55] defined the criteria for NOM: the patient must be hemodynamically stable, absence of peritoneal signs, availability of CT, monitoring in intensive care unit, facility of immediate surgery, and absence of other organ injuries. These criteria have become less strict, where multiple reports are trending more to NOM.[3] Other reports even went to the extreme suggesting that all patients should be treated first by NOM regardless of their trauma, provided the addition of angiography and embolization that made the NOM more feasible and more successful.[56],[57],[58] The success rate of nonoperative treatment has been remarkably high, and the necessity for operations for ongoing hemorrhage has been reported to be from 5% to 15%, but there remains a concern over missed bowel injuries that have been reported from 1% to 3%.[59],[60],[61],[62],[63] Nonoperative treatment of abdominal stab wounds has been practiced successfully in numerous centers and is on the rise.[1] NOM of gunshot wounds has been more controversial; however, many reports are calling to add these group of patients to the NOM group.[64],[65],[66],[67] Demetriades et al.[68] reported 152 patients with penetrating solid organ injuries recording that 28.4% of all liver injuries were successfully managed nonoperatively. Appropriately selected patients with liver gunshot injuries deemed feasible, safe, and effective, regardless of the liver injury severity in centers with suitable facilities.[67]

The failure rate of NOM ranges from 6% to 10% and it correlates with the grade of liver injury and this may arise from injuries that have not been recognized at the time of initial presentation and/or become apparent after initial delay.[1]

 Operative Management



Damage control surgery

This usually implies saving the patient's life and stopping the bleeding which will make the patient more stable and in a better physiological and hemodynamical state to be able to have the definitive treatment.[1] Skin preparation should allow for extension of a midline abdominal incision to a median sternotomy or right thoracotomy, if necessary, for adequate exposure of posterior liver injuries.[69],[70] If the indication for surgery is an obvious penetrating through-and-through liver injury, or the patient failed the NOM and has clear liver injury, only a bilateral subcostal incision is a useful alternative which has been adopted by many investigators to have better liver exposure.[1] DCS includes perihepatic packing and partial abdominal closure or Bogota bag.[69] Usually, an average of six laparotomy pads can be packed to get the tamponade effect between the liver and the abdominal wall.[70] The timing of re-exploration is controversial, but usually 12–24 h is the safe time for re-exploration if the patient's condition permits. As many hospitals have a general surgeon on call with limited liver or trauma experience, if a major liver injury is encountered, initial control of bleeding can be achieved with temporary tamponade of the right upper quadrant using packs, portal triad occlusion (Pringle maneuver), bimanual compression of the liver, or even manual compression of the abdominal aorta above the celiac trunk.[71],[72] Digital compression of the portal triad (Pringle maneuver) can be used diagnostically and compression can be maintained with an atraumatic vascular clamp if hemorrhage decreases and the clamp should be occluded only to the degree necessary to compress the blood vessels in order not to injure the common bile duct.[73] If hemorrhage is unaffected by portal triad occlusion, major vena cava injury or atypical vascular anatomy should be suspected.[74],[75] Although the permitted occlusion time of the portal triad is controversial, most authors now agree that clamping of the hepatic pedicle for up to 1 h is well tolerated with no adverse effects on liver function.[33],[69]

After initial intraoperative resuscitation, the liver must be mobilized adequately to allow a thorough examination of the damaged area and to decide on the necessary surgical technique, unless the injury is already accessible through the incision.[69],[72],[76] Mobilization is achieved by dividing the falciform, triangular and coronary ligaments, and by placing abdominal packs posteriorly to maintain this position.[50] Care should be taken to avoid impairing venous return, by either excessive lifting and/or rotation of the mobilized liver, or excessive packing causing caval compression.[1],[50] There are several tricks to stop the bleeding other than the one mentioned before, however we advise that most of these should be done by experienced surgeons in a stable patient or if the patient is still bleeding after trying the previous methods mentioned.[1] Several specific modalities began to be used more often to treat arterial bleeding as hepatorrhaphy has been used with increased frequency.[77] When the arterial bleeding occurred deep within the hepatic parenchyma, a tractotomy was advocated to expose and suture ligate the arterial flow, but control of deep arterial bleeding was often technically difficult to accomplish.[77],[78],[79] A high rate of infection following suture ligation of the deep arterial bleeding has led to reconsideration of its use, although it remained an operation that could occasionally be lifesaving.[80],[81],[82],[83],[84]

Major venous bleeding was recognized as a major source of mortality, particularly in patients who had been in high-speed motor vehicle crashes.[1] The nearly uniform lethality of retrohepatic vena caval injuries with an attempt at direct repair led to the development of the atriocaval shunt which was developed by Schrock et al.;[85] however, the operation required opening the chest to expose the atria which was associated with accelerated hypothermia and coagulopathy and the mortality rate remained high. Diffuse bleeding from damaged or devitalized liver increasingly required surgical treatment; however, resection debridement has been increasingly used in addition to the use of absorbable gauze packing and drainage or omental pedicle.[86],[87],[88]

 Definitive Surgery



This should be carried out in a stable patient by an experienced surgeon at a second stage to deal with a certain problem.[1] One of the most common problems is bile leak and collection with an incidence of 6%–20%.[89] Intra-abdominal collection is best treated by a radiological-guided drain and it can be investigated by MRCP or ERCP.[41],[89] ERCP is advocated by some to be much better where the leak is identified and can be treated by sphincterotomy and a stent with very high success rate; however, some patients still require surgical ligation.[41] Another reason to go to the operating room is liver necrosis and abscess formation which might increase with attempts to stop the bleeding with angioembolization in NOM or by arterial ligation and packing in DCS.[1] The best option for treating this problem is to drain the abscess radiologically; however, if drainage is not sufficient, operative drainage is advised.[1] Liver resection might be necessary with reported frequency of 2%–5% in most series, with an overall mortality of 17.8% and morbidity around 30%.[90],[91],[92]

Rebleeding in the postoperative period is a challenging problem and it may be related to coagulopathy, inadequate initial surgical repair, and missed retrohepatic venous injury.[1] Confirmed coagulation defects should be corrected as rapidly as possible with fresh frozen plasma and platelet transfusions. Some authors recommend reoperation after transfusion of 10 units of blood in 24 h;[93] however, the limit of 6 units in the first 12 h [94],[95] seems to be more reasonable. In cases with slow rebleeding when the limit of 6 units has not been exceeded, embolization of the bleeding vessels may be helpful.[95]

Intra-abdominal sepsis in the postoperative period occurs in approximately 7%–12% of patients and can be treated through radiological or surgical drainage.[96] Arteriovenous fistula is not an uncommon complication with an incidence of <3% and is usually treated by embolization.[97]

Liver transplantation has been reported as an extreme intervention in cases of severe and complicated hepatic trauma with twenty cases described in literature.[98] Esquivel et al. first reported the use of liver transplantation in two patients with progressive hepatic failure and uncontrollable bleeding.[99] The transplant decision is difficult because usual criteria are not validated, liver's potential recovery is difficult to evaluate, and associated sepsis and head injuries which may interfere with the proper decision.[100]

 Outcome



The mortality rate from liver trauma has fallen from 66% in the World War I, to 27% in the World War II, to current levels of 10%–15%.[101],[102] The mechanism of injury has an important bearing on mortality rate, with blunt trauma carrying a higher mortality rate (10%–30%) than penetrating liver trauma (0%–10%).[103]

 Conclusion



The better understanding of hepatic anatomy and pathophysiology, in addition to the advance in diagnostic imaging, resuscitation, intensive care, and the introduction of DCS, has led to marked improvement in the mortality rate following liver injury.

Financial support and sponsorship

Nil.

Conflicts of interest

There are no conflicts of interest.

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