Liver and kidney trauma - AAST grade V

Presentation

Municipal worker who has fallen from a 10-meter tree in a park while he was pruning the tree. Presents to the emergency department in a shocked state.

Patient Data

Age: 20 years
Gender: Male

Moderate hemoperitoneum is noted as well as multiple lacerations involving more than 75% of the right liver lobe. Several foci of active arterial bleeding present in the right liver lobe some extend beyond the liver capsule to the peritoneal cavity. The right hepatic vein and the portal branch of segment VII are not normally opacified, and partial thrombosis in the posterior right portal vein is noted (grade V AAST liver injury scale). The entire right kidney is devascularized (grade V AAST kidney injury scale). Abruptly cut-off of the right main renal artery is seen in the midpoint, with subtle focal dilation just before the cut-off.

Three pairs of arterial and corresponding portal phase images depict active arterial bleeding as a red circle in the arterial phase and a blue circle in the portal phase. Notice the change in the size and appearance of active bleeding in different post-contrast phases differentiating it from pseudoaneurysm. The blue arrow in the last image points to the devascularized right kidney, and the black shows the main right renal artery cut-off point.

Case Discussion

The patient went emergently to the operating room while resuscitating by IV fluid and packed cells. The majority of the right liver was disrupted - macerated with some hepatic fragments found in the pelvis. The foci of active bleeding packed with several elongases. No pulsatile or expansile retroperitoneal hematoma found, so no further retroperitoneal exploration was performed. A few hours later he again brought to the operating room with hypotension and blood oozing from the surgical incision and again underwent hepatic packing. The patient died from traumatic shock within 48 hours of admission.

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