Traumatic hepatic laceration
The patient was kicked in the abdomen by a horse. Clinically, she had bilateral tender sternum and ribs. A CT abdomen was performed as part of a CT trauma series.
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- Extensive oblique laceration (with capsular extension) is seen extending through both lobes (segments 4B and 5) of the liver. There is no definite active contrast extravasation. No definite portal vein injury is seen. The IVC and hepatic veins are patent and intact.
- Large amounts of hyperattenuating fluid (presumably blood) is seen surrounding liver and extending down bilateral paracolic gutters and into the pelvis. Markedly distended bladder. The bladder, however, appears intact.
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Liver injury is a common finding in many types of trauma 1. This is because of its anterior location, as well as its fragile parenchyma.
Investigations into traumatic liver injury involves focused assessment for trauma using ultrasound (FAST scans), CT, or with diagnostic peritoneal lavage. Radiography may reveal a rib fracture, a common associated injury.
Traumatic liver injury can be divided into six categories according to the American Association for the Surgery of Trauma 3. This particular patient had a grade III hepatic laceration.
- Grade I: Hematoma: subcapsular <10 percent surface area. Laceration: capsular tear <1 cm parenchymal depth
- Grade II: Hematoma: subcapsular 10 to 50 percent surface areaintraparenchymal <10 cm in diameter. Laceration: capsular tear 1 to 3 cm parenchymal depth, <10 cm in length.
- Grade III: Hematoma: subcapsular >50 percent of surface area or ruptured subcapsular or parenchymal hematoma; intraparenchymal hematoma >10 cm or expanding. Laceration >3 cm in depth.
- Grade IV: Laceration: parenchymal disruption involving 25 to 75 percent of a hepatic lobe, or 1 to 3 Couinaud segments.
- Grade V: Laceration: parenchymal disruption of >75 percent of a hepatic lobe, >3 Couinaud segments within a single lobe. Vascular: juxtahepatic venous injuries (retrohepatic vena cava, central major hepatic veins).
- Grade VI: Hepatic avulsion.
Patients can be managed based on their degree of haemodynamic stability 2. This is regardless of the grading of the injury. Stable patients are usually managed conservatively with supportive care. If there is extravasation of IV contrast, these lesions can be embolised via hepatic embolisation.
A haemodynamically compromised patient with a liver laceration is an indication for operative management. This can involve both damage control surgery, and liver resection in the severely compromised patient.
Case contributed by A/Prof. Pramit Phal.
- 1. 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
- 2. Stassen NA, Bhullar I, Cheng JD et-al. Nonoperative management of blunt hepatic injury: an Eastern Association for the Surgery of Trauma practice management guideline. J Trauma Acute Care Surg. 2012;73 (5 Suppl 4): S288-93. doi:10.1097/TA.0b013e318270160d - Pubmed citation
- 3. Tinkoff G, Esposito TJ, Reed J et-al. American Association for the Surgery of Trauma Organ Injury Scale I: spleen, liver, and kidney, validation based on the National Trauma Data Bank. J. Am. Coll. Surg. 2008;207 (5): 646-55. doi:10.1016/j.jamcollsurg.2008.06.342 - Pubmed citation