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:
- liver lacerations that extend to the bare area can be associated with a retroperitoneal haematoma or an adrenal haemorrhage
- liver lacerations that extend to the porta hepatis can be associated with bile duct injuries
- right lower lobe pulmonary contusion/laceration
- right sided rib fractures
- transverse process fractures
- right kidney injury
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
See main article liver injury grading for more details.
Treatment and prognosis
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:
- 1. Yoon W, Jeong YY, Kim JK et-al. CT in blunt liver trauma. Radiographics. 2005;25 (1): 87-104. Radiographics (full text) - doi:10.1148/rg.251045079 - Pubmed citation
- 2. Poletti PA, Mirvis SE, Shanmuganathan K et-al. CT criteria for management of blunt liver trauma: correlation with angiographic and surgical findings. Radiology. 2000;216 (2): 418-27. doi:10.1148/radiology.216.2.r00au44418 - Pubmed citation
- 3. Romano L, Giovine S, Guidi G et-al. Hepatic trauma: CT findings and considerations based on our experience in emergency diagnostic imaging. Eur J Radiol. 2004;50 (1): 59-66. doi:10.1016/j.ejrad.2003.11.015 - Pubmed citation
- 4. Hassan R, Abd Aziz A. Computed Tomography (CT) Imaging of Injuries from Blunt Abdominal Trauma: A Pictorial Essay. Malays J Med Sci. 2012;17 (2): 29-39. Free text at pubmed - Pubmed citation
- 5. Ahmed N, Vernick JJ. Management of liver trauma in adults. J Emerg Trauma Shock. 2011;4 (1): 114-9. doi:10.4103/0974-2700.76846 - Free text at pubmed - Pubmed citation
- 6. Ritchie AH, Williscroft DM. Elevated liver enzymes as a predictor of liver injury in stable blunt abdominal trauma patients: case report and systematic review of the literature. Can J Rural Med. 2007;11 (4): 283-7. Pubmed citation
- 7. Emergency Radiology. Springer. (2007) ISBN:3540689087. Read it at Google Books - Find it at Amazon