Liver trauma

Dr Craig Hacking and Dr Henry Knipe et al.

The liver is one of the most frequently damaged organs in blunt trauma, and liver trauma is associated with a significant mortality rate.

In blunt abdominal trauma, the liver is injured ~5% (range 1-10%) of the time 1,3.

Patients can present with right upper quadrant pain, right shoulder tip pain (from diaphragmatic irritation), hypotension and shock 3.

The mechanism for liver trauma can be from blunt (e.g. motor vehicle collision, fall, direct blow, etc.) or penetrating trauma (e.g. gunshot, stabbing). It can also be iatrogenic (e.g. percutaneous liver biopsy).

Most (~80%) of liver injuries are minor (grades I to III). There is a range of injuries:

  • laceration (most common)
  • haematoma - subcapsular or intraparenchymal
  • active haemorrhage
  • major hepatic vein injury
  • AV fistula

Approximately 80% of the liver injuries are associated with other abdominal injuries 1,3.

Within the liver:

  • lacerations that extend to the porta hepatis increase the risk bile duct injuries, particular delayed biliary complications 8
  • lacerations that involve a hepatic vein are associated with increased risk of arterial injury and need for operative management 8
  • although not an injury, periportal edema can be seen associated with liver injuries as patients with higher grade injuries will have received aggressive fluid resuscitation

Outside the liver (known as secondary signs):

Elevated liver transaminases (ALT/AST) is 100% specific and ~93% sensitive in predicting liver injuries 4,6.

CT is the investigation of choice for evaluating for liver trauma. It is ~95% sensitive and 99% specific for detecting liver injuries 5.

  • lacerations appear as irregular linear/branching areas of hypoattenuation
  • haematomas appear as a hypodensity between the liver and its capsule (and can be differentiated from intra-peritoneal haematoma as these distort the liver architecture) or can be intraparenchymal
  • acute haematomas/haemorrhage are typically hyperdense (40-60HU) compared to normal liver parenchyma
  • muscular diaphragmatic slips may simulate a peripheral laceration but are smoother, non-branching and of muscle density when compared to a laceration

If the liver is diffusely hypoattenuating, such as seen in steatosis, lacerations and haematomata may be more subtle to diagnose 8. Secondary signs should help.

See main article liver injury grading for more details.

Several mimics of liver lacerations and haematomata exist, and include 8:

  • focal fat infiltration
  • unenhanced aberrant portal or hepatic veins
  • congenital fissures and clefts: typically fat density, and in usualy locations
  • diaphragmatic slips or eventration: identifiable on coronal images
  • pre-existing liver lesions

Most (>80%) of liver injuries can be treated non-surgically, and in blunt trauma relies on haemodynamic stability rather than a grade of injury 4-5. There is a significant mortality rate of ~8% (range 4.1-11.7%) associated with liver trauma 1. Complications are reported in ~20% of cases of non-operatively treated liver trauma 7:

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Article information

rID: 26319
Section: Gamuts
Synonyms or Alternate Spellings:
  • Hepatic haematoma
  • Liver laceration
  • Hepatic trauma
  • Traumatic liver injuries
  • Liver haematoma
  • Hepatic laceration
  • Liver injury
  • Hepatic liver injury
  • Traumatic liver injury

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Cases and figures

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    Figure 1: injury grading diagrams
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    Case 1: liver laceration (gross pathology)
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    Liver lacerations...
    Case 2: with grade V renal injury
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    Case 3: grade IV liver laceration
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    Case 4: iatrogenic AF fistula
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    Case 5: laceration on ultrasound
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    Heterogeneous ech...
    Case 6: liver contusion with adrenal trauma
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    Case 7: post gun shot injury
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    Case 8: chronic subcapsular haematoma
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    Case 9
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    Case 10: liver laceration with rib fractures and pneumothorax
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