2.liver trauma pdf - د. دلير

LIVER TRAUMA

Dr. Dlair Omer

 Liver injuries are fortunately uncommon

–

*position under the diaphragm

*protected by the chest wall.

 However, when occurs, it is serious

divided into:
1. Blunt injury: produces contusion, laceration and avulsion

injuries to liver, m.b associated with splenic, mesenteric or
renal injury.

2. Penetrating injuries, such as stab and gunshot wounds, are

often associated with chest or pericardial involvement

At risk patients:
1. Stabbing/gunshot in lower chest or upper abdomen, esp if

severe hypotension

2. Severe Crush injury with multiple rib fractures, haemothorax

and S/S of shock

Diagnosis

1. CT

– scan with oral & iv contrast

2.  DPL
3.  FAST: determine haemoperitoneum
4.  Laparoscopy:

demonstrate

associated

diaphragmatic

rupture, Damage to the spleen and/or liver.

Hepatic organ injury scale
Grade I:

• hematoma subscapular, nonexpanding <10cm surface area
• Laceration capsular tear, nonbleeding, <1cm parenchymal

depth

Grade II:

•  hematoma subscapular, nonexpanding 10-50% surface area
•  Intraparenchymal nonexpanding <10cm diameter
•  Laceration  capsular  tear,  active  bleeding;  1-3cm  depth,

<10cm in length

Grade III:

• Hematoma subcapsular, >50% surface area or expanding;
• Ruptured subcapsular hematoma with active bleeding;

• Intraparenchymal hematoma >10cm or expanding;
• Laceration >3cm parenchymal depth

Grade IV:

• Hematoma ruptured intraparenchymal hematoma with active

bleeding;

• Laceration parenchymal disruption involving 25-75% of

hepatic lobe

Grade V:

• Laceration parenchymal disruption involving >75% of hepatic

lobe

• Vascular juxtahepatic venous injuries (vena cava, hepatic

veins)

Grade VI:

• Vascular hepatic avulsion

Management of liver trauma

 Haemodynamically stable pts: -- oral and intravenous

contrast-enhanced CT scan of the chest and abdomen. This
will demonstrate evidence of:

1.   parenchymal damage to liver or spleen
2.  associated traumatic injuries to their feeding vessels.
3.  Free fluid
4.

The chest scan: injuries to the great vessels and damage to the
lung parenchyma.

 Haemodynamically stable ---- conservative treatment
 Pts managed nonoperatively for solid organ injuries, but

when develop: Tachycardia, leukocytosis, hypotension,
metabolic acidosis, chang

es in abdominal examination→

may need surgery

 laparotomy and/or thoracotomy indicated in:

Haemodynamically unstable pts

pts with penetrating injuries

Pts with haemodynamic instability & evidence of positive DPL.

Findings on abdominal CT scan

 Pelvic collection
 Pneumoperitoneum

  Focal bowel wall thickening
  Mesenteric hematoma
  Mesenteric fat streaking
  Extravasation of oral & intravenous contrast

Initial management of liver injuries
Penetrating

1. A B C
2. Peripheral venous access: two large-bore cannulae and

blood for cross-match of 10 units of blood,

3. full blood count, urea and electrolytes, liver function tests,

clotting screen, glucose and amylase.

4. Initial volume replacement with colloid or O-negative blood if

necessary.

5. Intercostal chest drains inserted if associated pneumothorax

or haemothorax

6. transferred to the operating theatre,
7. frozen

plasma

and

cryoprecipitate:

rapidly

develop

irreversible coagulopathies due to a lack of fibrinogen and
clotting factors.

Blunt trauma:

1.  A B C
2.  Conservative Rx
3.  Surgery if: evidence of on-going blood loss despite correction

of coagulopathy and the development of signs of generalised
peritonitis.

The surgical approach to liver trauma

  A rooftop incision
  Suturing
  atraumatic clamp across the foramen of Winslow (the Pringle

manoeuvre).

 abdominal packs

complications of liver trauma

 A subcapsular or intrahepatic haematoma requires no

specific treatment

 Abscesses as a result of secondary infection of an area

parenchymal ischaemia.

 Bile collections, biliary fistulaIf
 hepatic artery aneurysm and arteriovenous or arteriobiliary

fistulae

 Hepatic failure may occur following extensive liver trauma.

Portal hypertension

 Normal portal venous pressure is 80-120mmH2O
 Portal HT

– 400mmH2O

 Oesoph varices bleeding

– wn reach 250-300mmH2O

 Sequelae: pphaematemesis, caput medusa, hypersplenisim

with

pancytopenia,

portal

vein

thrombosis,

ascites,

haemorrhoids,

Causes of PHT

1. Prehepatic: umblical sepsis, polycythemia, malignancy

obstruction, idiopathic

2. Intrahepatic: schisto, cong hepatic fibrosis, sarcoidosis, liver

intoxication, cirrhosis

3. Post-hepatic: hepatic vein obst, constrictive pericarditis

Usually  produce  no  symptoms,  But  diagnosed  following
presentation with chronic liver disease, encephalopathy, ascites or
variceal bleeding

Ix: CXR, Ba.swallow, IVU, Doppler-US, liver biopsy

 Absolute indication for elective surgery is bleeding

oesophageal varices

 Hypersplenisim & ascites: relative

Emergency Mx of bleeding varices

1.  Obtain periph & central venous access
2.  Adequate blood (10 units)
3.  LFT & coagulation profile
4.  Vitamin K (10mg) & FFP
5.  Oesoph ballon tamponade
6.  Drug Rx vasopressin * octreotide
7.  Endoscopic scleotherapy

8. Endoscopic banding
9. TIPSS: pts not responding to druds & endoscopy
10. Surgical shunts