Thursday, January 24, 2013

Liver trauma




Portal triad
Blood supply


Liver trauma is divided into:
  • Blunt and
  • Penetrating injuries
  • Blunt injury produces contusion, laceration and avulsion injury.
  • Penetrating injuries (like stab and gunshot wounds are often associated with chest or pericardial involvement.

Blunt force-liver injury
Penetrating injuries

Clinical features
  • Features of shock due to severe bleeding.(pallor, hypotension, tachycardia, sweating)
  • Distension of abdomen with dull flank, guarding, tenderness and rigidity.
  • Oliguria
  • Tachypnoea, respiratory distress and often cyanosis.
  • Rupture of right lobe is more common than the left lobe leading to haemoperitoneum.
  • Occasionally can cause localised hematoma which may form an abscess.
  • Bile leak from the injured site can lead to biliary peritonitis.

Investigations
  • Chest X-ray to look for the rib fracture.
  • USG abdomen
  • CT scan of chest and abdomen
  • Diagnostic peritoneal lavage
  • Hb%, PCV, blood groouping and cross matching.
  • Arterial blood gas analysis (ABG)
  • Coagulation profile.

Treatment :

General measures

Maintain airway
Breathing
Circulation-
  • I.V fluids, blood transfusion (massive), FFP
  • Have both central and peripheral venous access.
  • Bladder catheterization to measure the urine output

Specific treatment
  • Laparotomy is done through a large abdominal incision or thoracoabdominal incision, and extent of liver injury and also other associated injuries are looked for.
  • Small liver tear is sutured with absorbable sutures with placing of gel foam to control bleeding.
  • To control intraoperative bleeding, from hepatic artery and portal vein, both are temporarily occluded using fingers, compressing at foramen of Winslow. Often bull-dog clamp or vascular clamps can be used.
  • In deep severe injuries, following methods are used:
  1. Hepatic artery ligation
  2. Segmental resection
  3. Hemihepatectomy
  4. Packing the liver temporarily with mops.
  • Cholecystectomy and placement of “T” tube in CBD
  • In associated IVC injuries , it is very difficult to manage. A veno-venous bypass between femoral vein  and SVC is done and then repair of IVC is carried out.
  • ICT placement to thorax and repair of diaphragmatic injury.

Post operatively patients require:
  • Ventilator support
  • Blood transfusion
  • Electrolyte management
  • Antibiotics
  • FFP, cryoprecipitate

Complications and Sequelae of liver injury
  • Shock and haemorrhage
  • Intrahepatic haematoma
  • Liver abscess and septicaemia
  • Bile leak, biliary peritonitis, biliary fistulas
  • Disseminated intravascular coagulation
  • Hepatic artery aneurysm
  • Arterio-venous fistula
  • Arterio-biliary fistula
  • Electrolyte imbalance
  • Liver failure
  • Late sequelae
  • CBD stricture

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