Management of hepatic trauma in adults
- Ashley Britton Christmas, MD, FACS
Ashley Britton Christmas, MD, FACS
- Assistant Professor
- University of North Carolina at Chapel Hill Medical School
- David G Jacobs, MD
David G Jacobs, MD
- Professor of Surgery
- University of North Carolina at Chapel Hill Medical School
The liver is the most frequently injured abdominal organ. Most hepatic injuries are relatively minor and heal spontaneously with nonoperative management which consists of observation, and possibly arteriography and embolization [1,2]. Operative intervention to manage the liver injury is needed in about 14 percent of patients including those who initially present with hemodynamic instability or those who fail nonoperative management [2,3].
The diagnosis and management of hepatic injury in adults is reviewed here. Surgical techniques to manage liver injury are discussed in detail elsewhere. (See "Surgical techniques for managing hepatic injury".)
MECHANISM OF INJURY
The liver is the most commonly injured organ in blunt abdominal trauma and the second most commonly injured organ in penetrating abdominal trauma [3-6]. The liver is a highly vascular organ located in the right upper quadrant (figure 1) of the abdomen and is susceptible to injury from traumatic mechanisms. Among patients with blunt injury, motor vehicle collision is the most common injury mechanism . In patients with penetrating liver injury, the severity of injury depends upon the trajectory of the missile or implement and injuries can range from simple parenchymal to major vascular laceration.
The liver margin, which can usually be palpated 2 to 3 cm below the right rib margin, rises and falls with the diaphragm during respiration. The dome of the liver rises as high as the level of T4 (nipple) with expiration. Thus, injuries to the chest wall are often associated with significant injury to the liver. Similarly, the inferior margin of the liver descends to as low as T12 with deep inspiration, and injuries, particularly penetrating injuries, have the potential to injure the liver lower in the abdomen than might be expected. The posterior portion of the right lobe (figure 2) is the most common site of hepatic injury in blunt trauma .
We perform the initial resuscitation, diagnostic evaluation and management of the trauma patient with blunt or penetrating trauma based upon protocols from the Advanced Trauma Life Support (ATLS) program, established by the American College of Surgeons Committee on Trauma. The initial resuscitation and evaluation of the patient with blunt or penetrating abdominal or thoracic trauma is discussed in detail elsewhere.
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- MECHANISM OF INJURY
- TRAUMA EVALUATION
- History and physical examination
- Associated injuries
- Laboratory studies
- HEPATIC INJURY GRADING
- APPROACH TO MANAGEMENT
- NONOPERATIVE MANAGEMENT
- Contraindications to nonoperative management
- Hepatic embolization
- Benefits and risks of nonoperative management
- Failure of nonoperative management
- Follow-up care
- SURGICAL MANAGEMENT
- MORBIDITY AND MORTALITY
- SUMMARY AND RECOMMENDATIONS