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Injuries to the Liver and Biliary System

1. LIVER INJURIES

Etiology

  • Blunt injury – motor vehicle accident, fall
  • Penetrating – stab wound, gun shot
  • Iatrogenic – percutaneous liver biopsy

Types – contusion, laceration, avulsion, extension into thorax and biliary tree

  • Penetrating – often requires surgical intervention
    • Laceration is assessed; clots and blood in the peritoneal cavity is removed
    • Inferior vena cava control
    • Liver wound is sutured
    • Other injuries (of diaphragm, biliary system, bowel) should be looked for
  • Blunt trauma – assessed by CT
    • Treated conservatively
    • Indications for op – deterioration, bleeding, associated bowel injury, grade 5 liver injury on CT

Classification – AAST Classification

Grade I

  • Hematoma – subcapsular <10% surface area
  • Laceration – capsular tear <1cm parenchymal depth

Grade II

  • Hematoma – subcapsular 10-50% SA, intraparenchymal <10cm
  • Laceration – capsular tear 1-3cm parenchymal depth

Grade III

  • Hematoma – subcapsular >50% SA, intraparenchymal >10cm
  • Laceration – capsular tear >3cm parenchymal depth

Grade IV

  • Laceration – parenchymal disruption of 25-75% of lobe/involves 1-3 Couinaud segments

Grade V

  • Laceration – parenchymal disruption of >75% of lobe
  • Vascular – juxtahepatic venous injuries

Grade VI

  • Hepatic avulsion

Clinical features

  • Features of shock due to severe bleeding – pallor, hypotension, tachycardia, sweating
  • Distension of abdominal with dull flank, guarding, tenderness, rigidity
  • Oliguria
  • Tachypnoea, respiratory distress, cyanosis
  • Rupture of right lobe – haemoperitoneum
  • Bile leak from injured site – biliary peritonitis

Investigations

  • CXR – rib fractures
  • US abdomen
  • CT chest and abdomen – to grade the injuries (see above)
    • Acute hematoma/haemorrhage appear hyperdense compared to normal liver parenchyma
  • Hb%, PCV, blood grouping, cross matching
  • ABG analysis
  • Coagulation profile

Treatment

General measures

  • IV fluids, blood transfusion, fresh frozen plasma
  • Have both central venous access, and peripheral venous access
  • Bladder catheterisation – to measure urine output

Initial conservative non-operative management

  • Indicated for nonprogressive liver injures in patients who are haemodynamically stable, I-III grade liver injury, without peritoneal signs, normal mental status
  • Replacement of blood, prevention of sepsis, monitor Hct, LFT, PT
  • Angiographic embolisation
  • ICU management for 2-5, bed rest
  • Follow up CT is mandatory

Specific treatment

  • Laparotomy
  • Push, plug, Pringle’s manoeuvre, Pack
    • Push – direct compression
    • Plug – plugging the deep track injuries during silicone tube
    • Pringle’s manoeuvre – clamping of the hepatoduodenal ligament to limit blood flow through the hepatic artery and portal vein
    • Pack – liver would is packed with mop

2. INJURIES TO BILE DUCT

  • Penetrating trauma to extrahepatic bile duct is rare; it is usually associated with trauma to other viscera
  • Iatrogenic etiology is most common – cholecystectomies, mobilisation of duodenum during gastrectomy, liver resection
  • Can be noticed if there is an intra-operative bile leak

Clinical features

  • Fever, chills
  • Nausea, vomiting
  • Abdominal pain and distension
  • Jaundice

Investigations

  • If diagnosis is made during a cholecystectomy
    • Intra-operative cholangiogram – dye injected into the common bile duct and X-ray taken; shows any bile leakage
  • If diagnosis is not made during surgery
    • Transabdominal ultrasound
    • ERCP/MRCP

Management

  • Small injury may be managed with T-tube
  • Major injuries – Roux-en-Y procedure
  • Major injuries diagnosed post operative – transhepatic catheter for biliary decompression
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