This article is about traumatic liver injuries. For drug-induced liver injury, see Hepatotoxicity.
A liver injury, also known as liver laceration, is some form of trauma sustained to the liver. This can occur through either a blunt force such as a car accident, or a penetrating foreign object such as a knife.[1] Liver injuries constitute 5% of all traumas, making it the most common abdominal injury.[2] Generally nonoperative management and observation is all that is required for a full recovery.
Given its anterior position in the abdominal cavity and its large size, the liver is prone to gun shot wounds and stab wounds.[2] Its firm location under the diaphragm also makes it especially prone to shearing forces.[1] Common causes of this type of injury are blunt force mechanisms such as motor vehicle accidents, falls, and sports injuries. Typically these blunt forces dissipate through and around the structure of the liver[3] and causes irreparable damage to the internal microarchitecture of the tissue.[4] With increasing velocity of the impact, the internal damage of the liver tissue also exemplifies[clarification needed] - even though the tissue itself is mechanically and micro-structurally isotropic.[5] A large majority of people who sustain this injury also have another accompanying injury.[1]
Diagnosis
Grade 4 liver laceration
Imaging, such as the use of ultrasound or a computed tomography scan, is the generally preferred way of diagnosis as it is more accurate and is sensitive to bleeding, however; due to logistics this is not always possible.[6] For a person who is hemodynamically unstable a focused assessment with sonography for trauma (FAST) scan may take place which is used to find free floating fluid in the right upper quadrant and left lower quadrant of the abdomen. The FAST scan however may not be indicated in those who are obese and those with subcutaneous emphysema.[7] Its speed and sensitivity to injuries resulting in 400mL of free-floating fluid make it a valuable tool in the evaluation of unstable persons. Computed tomography is another diagnostic study which can be performed, but typically is only used in those who are hemodynamically stable.[7] A physical examination may be used but is typically inaccurate in blunt trauma, unlike in penetrating trauma where the trajectory the projectile took can be followed digitally.[8] A diagnostic peritoneal lavage (DPL) may also be utilized but has limited application as it is hard to determine the origin of the bleeding.[9] A diagnostic peritoneal lavage is generally discouraged when FAST is available as it is invasive and non-specific.[7]
Liver injuries are classified on a Roman numeral scale with I being the least severe, to VI being the most severe. Generally any injury ≥III requires surgery.[3][10]
Management
The initial management of liver trauma generally follows the same procedures for all traumas with a focus on maintaining airway, breathing, and circulation. A physical examination is a cornerstone of the assessment of which there are various non-invasive means of diagnostic tools that can be utilized.[3] An invasive diagnostic peritoneal lavage can also be used to diagnose and classify the extent of the damage.[11][12] A large majority of liver injuries are minor and require only observation.[13] Generally if there is estimated to be less than 300mL of free floating fluid, no injury to surrounding organs, and no need for blood transfusion, there is a low risk of complication from nonoperative management.[1] In special cases where there is a higher risk with surgery, such as in the elderly, nonoperative management would include the infusion of packed red blood cells in an intensive care unit.[2] Typically hepatic injuries resulting from stab wounds cause little damage unless a vital part of the liver is injured, such as the hepatic portal vein; with gunshot wounds, the damage is worse.[14]
Surgery
In severe liver injuries (class ≥III), or those with hemodynamic instability, surgery is generally necessary.[7] Surgical techniques such as perihepatic packing or the use of the Pringle manoeuvre can be used to control hemorrhage.[2][3] Temporary control of the hemorrhage can be accomplished through direct manual pressure to the wound site.[2] In these severe cases it is important to prevent the progression of the trauma triad of death, which often requires the utilization of damage control surgery.[12] New devices are being developed in order to control the bleeding using negative pressure.[15]
The common cause of death while operating is exsanguination caused by profuse loss of blood volume.[16] Rarely, surgery entails the use of liver resection, which removes the source of the bleeding and necrotic tissue. The drastic nature of this procedure means it can only be used in hemodynamically stable patients.[10] Another rare procedure would be liver transplantation which is typically impractical due to the logistics of finding a proper organ donor in a timely fashion.[17]
History
In the 1880s a severe liver injury would in most cases prove fatal in the first 24 hours after sustaining the injury.[18] Before the 1980s nonoperative management was seldom used in favor of the methods of management suggested by James Hogarth Pringle.[19][20] During World War II the use of early laparotomy was popularized and in conjunction with the use of transfusions, advanced anesthetics, and other new surgical techniques led to decreased mortality.[21]
References
^ abcdePiper GL, Peitzman AB (August 2010). "Current management of hepatic trauma". The Surgical Clinics of North America. 90 (4): 775–85. doi:10.1016/j.suc.2010.04.009. PMID 20637947.
^ abcdefCothren CC, Moore EE (August 2008). "Hepatic Trauma". European Journal of Trauma and Emergency Surgery. 34 (4): 339–54. doi:10.1007/s00068-008-8029-5. PMID 26815811. S2CID 22788477.
^ abcdBouras AF, Truant S, Pruvot FR (December 2010). "Management of blunt hepatic trauma". Journal of Visceral Surgery. 147 (6): e351-8. doi:10.1016/j.jviscsurg.2010.10.004. PMID 21111696.
^Chen J, Brazile B, Prabhu R, Patnaik SS, Bertucci R, Rhee H, Horstemeyer MF, Hong Y, Williams LN, Liao J (July 2018). "Quantitative Analysis of Tissue Damage Evolution in Porcine Liver With Interrupted Mechanical Testing Under Tension, Compression, and Shear". Journal of Biomechanical Engineering. 140 (7): 071010. doi:10.1115/1.4039825. PMC5938066. PMID 29715364.
^Williams, Lakiesha N.; Liao, Jun; Horstemeyer, Mark F.; Marin, Esteban; Bouvard, Jean-Luc; Priddy, Lauren B.; Prabhu, R. K.; Patnaik, Sourav S.; Chen, Joseph (June 2019). "Mechanical Response of Porcine Liver Tissue under High Strain Rate Compression". Bioengineering. 6 (2): 49. doi:10.3390/bioengineering6020049. PMC6630843. PMID 31151177.
^American College of Surgeons (2004). Atls, Advanced Trauma Life Support Program for Doctors. Amer College of Surgeons. ISBN978-1-880696-14-9.
^Kenneth D. Boffard (2007). Manual of definitive surgical trauma care. London: Hodder Arnold. pp. 108. ISBN978-0-340-94764-7.
^Segura-Sampedro, Juan José; Pineño-Flores, Cristina; Craus-Miguel, Andrea; Morales-Soriano, Rafael; González-Argente, Francesc Xavier (2019-12-16). "New hemostatic device for grade IV–V liver injury in porcine model: a proof of concept". World Journal of Emergency Surgery. 14 (1): 58. doi:10.1186/s13017-019-0277-7. ISSN 1749-7922. PMC6916102. PMID 31889989.
^Ahmed I, Beckingham IJ (2007). "Liver trauma". Trauma. 9 (3): 171–180. doi:10.1177/1460408607086775. S2CID 208270204.
^Parks RW, Chrysos E, Diamond T (September 1999). "Management of liver trauma". The British Journal of Surgery. 86 (9): 1121–35. doi:10.1046/j.1365-2168.1999.01210.x. PMID 10504364. S2CID 40857849.
^Moynihan BB (1906). Abdominal operations. Saunders. p. 563. Retrieved 2012-08-04.
^Pringle JH (October 1908). "V. Notes on the Arrest of Hepatic Hemorrhage Due to Trauma". Annals of Surgery. 48 (4): 541–9. doi:10.1097/00000658-190810000-00005. PMC1406963. PMID 17862242.
Feliciano DV, Mattox KL, Moore EJ (2012). Trauma, Seventh Edition (Trauma (Moore)). McGraw-Hill Professional. ISBN978-0-07-166351-9.
Peitzman AB, Sabom M, Yearly DM, Fabian TC (2002). The trauma manual. Hagerstwon, MD: Lippincott Williams & Wilkins. ISBN978-0-7817-2641-2.
External links
January 29, 2023
liver, injury, this, article, about, traumatic, liver, injuries, drug, induced, liver, injury, hepatotoxicity, liver, injury, also, known, liver, laceration, some, form, trauma, sustained, liver, this, occur, through, either, blunt, force, such, accident, pene. This article is about traumatic liver injuries For drug induced liver injury see Hepatotoxicity A liver injury also known as liver laceration is some form of trauma sustained to the liver This can occur through either a blunt force such as a car accident or a penetrating foreign object such as a knife 1 Liver injuries constitute 5 of all traumas making it the most common abdominal injury 2 Generally nonoperative management and observation is all that is required for a full recovery Liver injuryAn extensive rupture of the liverSpecialtyEmergency medicine Contents 1 Cause 2 Diagnosis 2 1 Classification 3 Management 3 1 Surgery 4 History 5 References 6 Bibliography 7 External linksCause EditGiven its anterior position in the abdominal cavity and its large size the liver is prone to gun shot wounds and stab wounds 2 Its firm location under the diaphragm also makes it especially prone to shearing forces 1 Common causes of this type of injury are blunt force mechanisms such as motor vehicle accidents falls and sports injuries Typically these blunt forces dissipate through and around the structure of the liver 3 and causes irreparable damage to the internal microarchitecture of the tissue 4 With increasing velocity of the impact the internal damage of the liver tissue also exemplifies clarification needed even though the tissue itself is mechanically and micro structurally isotropic 5 A large majority of people who sustain this injury also have another accompanying injury 1 Diagnosis Edit Grade 4 liver laceration Imaging such as the use of ultrasound or a computed tomography scan is the generally preferred way of diagnosis as it is more accurate and is sensitive to bleeding however due to logistics this is not always possible 6 For a person who is hemodynamically unstable a focused assessment with sonography for trauma FAST scan may take place which is used to find free floating fluid in the right upper quadrant and left lower quadrant of the abdomen The FAST scan however may not be indicated in those who are obese and those with subcutaneous emphysema 7 Its speed and sensitivity to injuries resulting in 400mL of free floating fluid make it a valuable tool in the evaluation of unstable persons Computed tomography is another diagnostic study which can be performed but typically is only used in those who are hemodynamically stable 7 A physical examination may be used but is typically inaccurate in blunt trauma unlike in penetrating trauma where the trajectory the projectile took can be followed digitally 8 A diagnostic peritoneal lavage DPL may also be utilized but has limited application as it is hard to determine the origin of the bleeding 9 A diagnostic peritoneal lavage is generally discouraged when FAST is available as it is invasive and non specific 7 Classification Edit The Liver Injury Scale classification 1 2 Grade Subcapsular hematoma LacerationI lt 10 surface area lt 1 cm in depthII 10 50 surface area 1 3 cmIII gt 50 or gt 10 cm gt 3 cmIV 25 75 of a hepatic lobeV gt 75 of a hepatic lobeVI Hepatic avulsionLiver injuries are classified on a Roman numeral scale with I being the least severe to VI being the most severe Generally any injury III requires surgery 3 10 Management EditThe initial management of liver trauma generally follows the same procedures for all traumas with a focus on maintaining airway breathing and circulation A physical examination is a cornerstone of the assessment of which there are various non invasive means of diagnostic tools that can be utilized 3 An invasive diagnostic peritoneal lavage can also be used to diagnose and classify the extent of the damage 11 12 A large majority of liver injuries are minor and require only observation 13 Generally if there is estimated to be less than 300mL of free floating fluid no injury to surrounding organs and no need for blood transfusion there is a low risk of complication from nonoperative management 1 In special cases where there is a higher risk with surgery such as in the elderly nonoperative management would include the infusion of packed red blood cells in an intensive care unit 2 Typically hepatic injuries resulting from stab wounds cause little damage unless a vital part of the liver is injured such as the hepatic portal vein with gunshot wounds the damage is worse 14 Surgery Edit In severe liver injuries class III or those with hemodynamic instability surgery is generally necessary 7 Surgical techniques such as perihepatic packing or the use of the Pringle manoeuvre can be used to control hemorrhage 2 3 Temporary control of the hemorrhage can be accomplished through direct manual pressure to the wound site 2 In these severe cases it is important to prevent the progression of the trauma triad of death which often requires the utilization of damage control surgery 12 New devices are being developed in order to control the bleeding using negative pressure 15 The common cause of death while operating is exsanguination caused by profuse loss of blood volume 16 Rarely surgery entails the use of liver resection which removes the source of the bleeding and necrotic tissue The drastic nature of this procedure means it can only be used in hemodynamically stable patients 10 Another rare procedure would be liver transplantation which is typically impractical due to the logistics of finding a proper organ donor in a timely fashion 17 History EditIn the 1880s a severe liver injury would in most cases prove fatal in the first 24 hours after sustaining the injury 18 Before the 1980s nonoperative management was seldom used in favor of the methods of management suggested by James Hogarth Pringle 19 20 During World War II the use of early laparotomy was popularized and in conjunction with the use of transfusions advanced anesthetics and other new surgical techniques led to decreased mortality 21 References Edit a b c d e Piper GL Peitzman AB August 2010 Current management of hepatic trauma The Surgical Clinics of North America 90 4 775 85 doi 10 1016 j suc 2010 04 009 PMID 20637947 a b c d e f Cothren CC Moore EE August 2008 Hepatic Trauma European Journal of Trauma and Emergency Surgery 34 4 339 54 doi 10 1007 s00068 008 8029 5 PMID 26815811 S2CID 22788477 a b c d Bouras AF Truant S Pruvot FR December 2010 Management of blunt hepatic trauma Journal of Visceral Surgery 147 6 e351 8 doi 10 1016 j jviscsurg 2010 10 004 PMID 21111696 Chen J Brazile B Prabhu R Patnaik SS Bertucci R Rhee H Horstemeyer MF Hong Y Williams LN Liao J July 2018 Quantitative Analysis of Tissue Damage Evolution in Porcine Liver With Interrupted Mechanical Testing Under Tension Compression and Shear Journal of Biomechanical Engineering 140 7 071010 doi 10 1115 1 4039825 PMC 5938066 PMID 29715364 Williams Lakiesha N Liao Jun Horstemeyer Mark F Marin Esteban Bouvard Jean Luc Priddy Lauren B Prabhu R K Patnaik Sourav S Chen Joseph June 2019 Mechanical Response of Porcine Liver Tissue under High Strain Rate Compression Bioengineering 6 2 49 doi 10 3390 bioengineering6020049 PMC 6630843 PMID 31151177 Moore 2012 p 543 a b c d Coccolini F Montori G Catena F Di Saverio S Biffl W Moore EE Peitzman AB Rizoli S Tugnoli G Sartelli M Manfredi R Ansaloni L 2015 01 01 Liver trauma WSES position paper World Journal of Emergency Surgery 10 39 doi 10 1186 s13017 015 0030 9 PMC 4548919 PMID 26309445 Pietzman 2002 p 255 Moore 2012 p 542 a b Krawczyk M Arkuszewski P 2009 Surgical Management of Liver Trauma Polish Journal of Surgery 81 11 554 doi 10 2478 v10035 009 0090 1 S2CID 12453253 Moore 2012 p 541 a b Stracieri LD Scarpelini S 2006 Hepatic injury Acta Cirurgica Brasileira 21 Suppl 1 85 8 doi 10 1590 s0102 86502006000700019 PMID 17013521 American College of Surgeons 2004 Atls Advanced Trauma Life Support Program for Doctors Amer College of Surgeons ISBN 978 1 880696 14 9 Kenneth D Boffard 2007 Manual of definitive surgical trauma care London Hodder Arnold pp 108 ISBN 978 0 340 94764 7 Segura Sampedro Juan Jose Pineno Flores Cristina Craus Miguel Andrea Morales Soriano Rafael Gonzalez Argente Francesc Xavier 2019 12 16 New hemostatic device for grade IV V liver injury in porcine model a proof of concept World Journal of Emergency Surgery 14 1 58 doi 10 1186 s13017 019 0277 7 ISSN 1749 7922 PMC 6916102 PMID 31889989 Ahmed I Beckingham IJ 2007 Liver trauma Trauma 9 3 171 180 doi 10 1177 1460408607086775 S2CID 208270204 Parks RW Chrysos E Diamond T September 1999 Management of liver trauma The British Journal of Surgery 86 9 1121 35 doi 10 1046 j 1365 2168 1999 01210 x PMID 10504364 S2CID 40857849 Moynihan BB 1906 Abdominal operations Saunders p 563 Retrieved 2012 08 04 Pringle JH October 1908 V Notes on the Arrest of Hepatic Hemorrhage Due to Trauma Annals of Surgery 48 4 541 9 doi 10 1097 00000658 190810000 00005 PMC 1406963 PMID 17862242 Feliciano DV Rozycki GS 2002 Hepatic trauma Scandinavian Journal of Surgery 91 1 72 9 doi 10 1177 145749690209100112 PMID 12075841 Moore 2012 p 539Bibliography EditFeliciano DV Mattox KL Moore EJ 2012 Trauma Seventh Edition Trauma Moore McGraw Hill Professional ISBN 978 0 07 166351 9 Peitzman AB Sabom M Yearly DM Fabian TC 2002 The trauma manual Hagerstwon MD Lippincott Williams amp Wilkins ISBN 978 0 7817 2641 2 External links Edit Retrieved from https en wikipedia org w index php title Liver injury amp oldid 1136287594, wikipedia, wiki, book, books, library,
