Liver Trauma (Liver Injury)

What is Liver Trauma (Liver Injury)?

The liver is often the most affected organ when someone experiences a blunt force impact to the abdomen. Due to its large size, it also tends to be hurt often in injuries involving penetration of the abdominal area. The severity of liver damage can vary – from minor cuts or internal bleeding with a low risk of serious health issues, to intense trauma which can be fatal. The American Association for the Surgery of Trauma has a ranking system to grade the severity of liver injuries, which can be useful in assessing minor liver traumas.

To treat these liver injuries, medical imaging procedures performed by radiologists can be used. Endoscopy – a procedure that involves using special instruments to view and operate on the internal organs and vessels, can also help treat patients. In cases of severe liver trauma, extensive efforts to replenish lost blood, surgical procedures, and emergency surgery aimed at controlling hemorrhage and contamination may be required. This piece gives a broad understanding of how to take care of patients with liver trauma.

What Causes Liver Trauma (Liver Injury)?

A liver injury from trauma is pretty common in cases of both harsh and piercing injuries to the abdomen. The liver is located at the front of the abdomen and it’s quite delicate. It’s also easy for its outer covering to be broken. Because of this, the liver is often injured by blunt force. Its fixed position right under the diaphragm also makes it prone to injuries triggered by sudden slowing down or stopping.

The liver has large blood vessels that are thin and carry a lot of blood. Blunt trauma to the abdomen is typically caused by car crashes, accidents where someone is hit by a car, or falls. Injuries to the liver can also occur from accidents in farming or industrial settings. In addition, the liver’s front-facing position and big size compared to other organs in the abdomen make it likely to be hurt by penetrating injuries like gunshot or stab wounds.

The right side of the liver is the part most often injured in both blunt and penetrating trauma.

Risk Factors and Frequency for Liver Trauma (Liver Injury)

Liver injuries account for around 5% of all cases of trauma that result in hospital admission. The liver is the organ most often injured in accidents that cause blunt force trauma, and these cases often involve other injuries as well. The severity of liver damage can vary, with minor injuries being the most common, accounting for 80% to 90% of all liver trauma cases.

Liver injuries are rated on a scale from 1 to VI.
The risk of death increases with the severity of the liver injury.
Grade VI injuries, the most severe kind, are often lethal.
Liver damage is the main cause of death in serious abdominal trauma, with a death rate of 10% to 15%.

Signs and Symptoms of Liver Trauma (Liver Injury)

If you get injured in your liver area, it’s important that the medical team starts care for you in the trauma bay. What the first responders tell doctors and nurses about how the injury happened could be vital. This could help them figure out if there’s a chance of a liver injury. Damage to the front wall, the side or the upper part of your abdomen may lead to a suspicion of a liver issue.

Like other trauma patients, the evaluation should follow the principles of advanced trauma life support. An immediate evaluation, called the “primary survey”, is usually done to detect life-threatening injuries straight away. During this, the healthcare team should spot if you’re in shock because of bleeding from a liver injury. Signs of this type of shock can include a small difference between your systolic and diastolic blood pressure, low blood pressure, and a fast heart rate.

Once the first review has been done, a “secondary survey” should take place. This is a full check over your entire body that could point out other potential injuries. Right upper abdomen tenderness and a swollen stomach may hint at a liver injury and bleeding in the abdominal cavity.

Testing for Liver Trauma (Liver Injury)

If you’re a patient in a trauma unit, standard laboratory tests are often ordered based on the type of injury. These tests can include a comprehensive check of your body’s chemical balance, complete blood count to look at your overall health, tests for blood clotting, and a lactate level test, which measures the amount of lactate (a type of acid) in your blood. Your liver function may also be checked, though any potential abnormalities might not be noticeable until a few hours or even days after the injury.

Imaging assessments are another key component in evaluating injuries. One common assessment conducts in the trauma unit is called the FAST exam: Focused Assessment with Sonography for Trauma. This exam uses ultrasound technology to check if there’s any internal bleeding in the abdomen or around the heart. However, it doesn’t indicate the extent of the organ injury. The results of a FAST exam can vary depending on the person conducting the exam and can help doctors decide if a patient with a liver injury should be immediately sent to surgery.

Patients who are stable after initial treatments can undergo more imaging tests like a CT scan of the abdomen and pelvis. This scan, typically administered with an intravenous (IV) contrast, is a common procedure to help identify liver injuries. What’s helpful about a CT scan is that it provides detailed images of the liver, helps rate the severity of the injury, identifies other abdominal injuries, and estimates the amount of blood in the abdominal cavity. It can highlight the presence of any active blood loss, which helps decide if further surgical or radiological interventions are needed.

Magnetic resonance cholangiopancreatography (MRCP), a type of MRI, isn’t typically used in an urgent trauma situation because it’s quite time-consuming. However, if there’s a suspicion that the bile ducts, which carry bile from the liver to the intestines, have been damaged or are leaking, an MRCP might be considered.

Based on the results from these imaging tests, injuries to the liver are classified according to a grading system established by the American Association for the Surgery of Trauma. While the grade doesn’t solely decide the course of treatment, it’s noticed that higher-grade injuries are often associated with a higher risk of death and unsuccessful non-surgical treatments.

Treatment Options for Liver Trauma (Liver Injury)

In patients with stable vital signs, non-surgical treatment is commonly recommended for blunt liver injuries according to guidelines from the Eastern Association for the Surgery of Trauma Practice. However, it’s crucial that this treatment is provided in a facility equipped for close monitoring, repeated abdominal examinations, and has an operating room ready for emergency surgery if needed. Patients given this non-surgical treatment usually stay in the Intensive Care Unit (ICU), where they’re monitored closely. Despite the success of this treatment in many cases, patients with more severe liver injuries are more likely to need additional interventions. Frostbite, blood loss, and other unstable conditions are often the reasons behind treatment failure.

On rare occasions, non-surgical treatment might be suitable for patients with certain types of penetrating injuries who are in stable condition. For example, victims of stab wounds or low-velocity gunshot wounds confined to the upper right region of the abdomen might be good candidates for non-surgical treatment. However, these patients must go through rigorous medical examinations before getting this treatment, and similar to patients with blunt injuries, they also require close monitoring in the ICU.

Selective embolization or the intentional blocking of blood vessels using angiography is an effective technique especially in patients with blunt hepatic injuries. It has a very high success rate, but when to use it and in which patients remains a point of debate. Some doctors prefer to use it for blunt liver injuries higher than grade III, while others only consider it if a CT scan shows leakage of contrast dye.

On the other hand, patients with unstable vital signs who don’t respond to resuscitation should be taken straight to the operating room for surgery. Notably, patients who do not respond to non-surgical treatment must also undergo surgery. In this situation, a type of surgery called a ‘damage control’ laparotomy may be carried out. It aims at initially controlling the bleeding and then controlling contamination from the gastrointestinal tract. In cases where the standard methods to stop the bleeding are not enough, more advanced techniques may be necessary.

In addition to surgical interventions, other treatments can also be employed to manage liver injuries. Techniques like endoscopic retrograde cholangiopancreatography (ERCP) can be used to identify and treat bile duct injuries. Stents can be placed using ERCP to help heal bile duct injuries. Interventional radiology can also be useful in draining collections of infected or bilious fluid that have resulted from liver trauma.

Home abuse
Bleeding severely enough to cause shock
Shock from loss of body fluids
Injuries to the lower urinary and reproductive organs
Injuries from objects penetrating the abdomen
Physical harm during pregnancy
Injuries to the upper urinary and reproductive organs

Possible Complications When Diagnosed with Liver Trauma (Liver Injury)

After a liver trauma, there can be several complications that are important to be aware of. One of the most common complications is a bile leak, which can occur in about 21% of patients who undergo surgery. Other potential complications include hepatic abscesses which are often a result of tying off the hepatic artery or a procedure known as angioembolization. There’s also the risk of hepatic necrosis, or liver cell death, especially in those who undergo angioembolization — this can affect up to 41% of patients. These people might show symptoms such as fever and increased white blood cell count. If the symptoms are mild, they can be given hydration through IV, but those with more serious inflammation might require further procedures such as insertion of a drain by a radiologist, repeated operative cleansing of the wound, or even liver resection.

Another potential but rare complication from liver trauma could be the formation of an abnormal connection between the blood vessels and bile ducts leading to a condition called hemobilia. This can cause blood clotting and obstruction of the bile ducts. Hemobilia can cause symptoms similar to a classic digestive tract bleed, plus jaundice and upper abdominal pain. These conditions can be treated with selective angioembolization but severe cases might require surgical intervention, either tying off the feeding blood vessel or removing part of the liver.

Frequently asked questions

Liver trauma, also known as liver injury, refers to damage to the liver caused by blunt force impact or penetration of the abdominal area. The severity of liver damage can vary, ranging from minor cuts or internal bleeding to intense trauma that can be fatal.

Liver injuries account for around 5% of all cases of trauma that result in hospital admission.

Signs and symptoms of Liver Trauma (Liver Injury) include: - Damage to the front wall, side, or upper part of the abdomen may lead to a suspicion of a liver issue. - In the primary survey, signs of shock due to bleeding from a liver injury can include a small difference between systolic and diastolic blood pressure, low blood pressure, and a fast heart rate. - Right upper abdomen tenderness and a swollen stomach may hint at a liver injury and bleeding in the abdominal cavity.

Liver trauma or liver injury can occur as a result of both blunt and penetrating injuries to the abdomen. Blunt trauma to the abdomen can be caused by car crashes, accidents where someone is hit by a car, falls, or accidents in farming or industrial settings. Penetrating injuries, such as gunshot or stab wounds, can also cause liver trauma. The right side of the liver is the part most often injured in both blunt and penetrating trauma.

The doctor needs to rule out the following conditions when diagnosing Liver Trauma (Liver Injury): - Home abuse - Bleeding severely enough to cause shock - Shock from loss of body fluids - Injuries to the lower urinary and reproductive organs - Injuries from objects penetrating the abdomen - Physical harm during pregnancy - Injuries to the upper urinary and reproductive organs

The types of tests that a doctor would order to properly diagnose liver trauma (liver injury) include: - Comprehensive check of the body's chemical balance - Complete blood count (CBC) to assess overall health - Tests for blood clotting - Lactate level test to measure the amount of lactate in the blood - Liver function tests to check for any abnormalities - Imaging assessments such as a FAST exam (Focused Assessment with Sonography for Trauma) to check for internal bleeding in the abdomen or around the heart - CT scan of the abdomen and pelvis with IV contrast to identify liver injuries, assess severity, and detect other abdominal injuries - Magnetic resonance cholangiopancreatography (MRCP) if there is suspicion of bile duct damage or leakage - Grading system established by the American Association for the Surgery of Trauma to classify liver injuries - Additional interventions such as selective embolization using angiography for blunt hepatic injuries or surgery for patients with unstable vital signs or non-responsive to non-surgical treatment - Other treatments like endoscopic retrograde cholangiopancreatography (ERCP) to identify and treat bile duct injuries and interventional radiology for draining collections of infected or bilious fluid resulting from liver trauma.

Liver trauma, or liver injury, can be treated through non-surgical methods in patients with stable vital signs. This treatment is recommended by guidelines from the Eastern Association for the Surgery of Trauma Practice. However, it is important that this treatment is provided in a facility equipped for close monitoring, repeated abdominal examinations, and emergency surgery if needed. Patients receiving non-surgical treatment usually stay in the Intensive Care Unit (ICU) for close monitoring. In more severe cases, additional interventions may be necessary. For patients with certain types of penetrating injuries who are in stable condition, non-surgical treatment may also be suitable after rigorous medical examinations. Selective embolization, a technique that blocks blood vessels using angiography, can be effective for blunt hepatic injuries. Patients with unstable vital signs who do not respond to resuscitation should be taken straight to the operating room for surgery. Other treatments, such as endoscopic retrograde cholangiopancreatography (ERCP) and interventional radiology, can also be used to manage liver injuries.

The side effects when treating Liver Trauma (Liver Injury) can include: - Bile leak, which can occur in about 21% of patients who undergo surgery. - Hepatic abscesses, which can result from tying off the hepatic artery or angioembolization. - Hepatic necrosis, or liver cell death, especially in those who undergo angioembolization. This can affect up to 41% of patients and may cause symptoms such as fever and increased white blood cell count. - Formation of an abnormal connection between blood vessels and bile ducts, leading to a condition called hemobilia. This can cause blood clotting and obstruction of the bile ducts, resulting in symptoms similar to a digestive tract bleed, jaundice, and upper abdominal pain. Severe cases might require surgical intervention, such as tying off the feeding blood vessel or removing part of the liver.

The prognosis for liver trauma (liver injury) can vary depending on the severity of the injury. Here are some key points to consider: - Minor injuries are the most common and have a low risk of serious health issues. - Grade VI injuries, the most severe kind, are often lethal. - Liver damage is the main cause of death in serious abdominal trauma, with a death rate of 10% to 15%.

A radiologist or a surgeon.