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• Largest solid abdominal organ,fixed position • Second most common injured, but most
common cause of death after abdominal trauma
• Blunt MVA most common • 80% adults, 97% children-conservative rx
• Friable parenchyma, thin capsule, fixed position in relation to spine.
• Right lobe gets hit more since its larger, and closer to ribs.
• 85% injuries involve segments 6,7,8 from compressioin against ribs, spine, abd wall.
• Shear forces at attachments to diaphragm • Transmission thru right hemithorax.
• Liver injured easily in children since ribs are compliant, force transmitted.
• Liver not as developed in children, with weaker connective tissue framework.
• Iatrogenic injuries by biopsies, biliary drainage, TIPS, can cause capsular tears and bile leaks, fistulas, hemoperitoneum.
• Subcapsular hematoma or intrahepatic hematoma. • Laceration • Contusion • Hepatic vascular disruption • Bile duct injury • 86% of injuries have stopped bleeding at time of
exploration. • Decreased transfusion req.With conservative.
• Mild hepatic injuries involving < 25% of one lobe heal in 3 mos.
• Moderate injuries involving 25-50% of one lobe heal in 6 mos.
• Sever injuries require 9-15 mos to heal. • Gallbladder injuries rare, with contusons being
most common, avulsions next most.
• Cantile described main divisions along a main plane from GB fossa to IVC. Divides liver into equal halves.
• Couinaud developed 4 sectors and 8 segments, divided into vertical and oblique planes, defined by the 3 main hepatic veins and transverse plane thru right and left portal branches.
• Hepatic veins lie between segments. • Left hepatc vein divides left lobe into medial
and lateral segments. • Middle hepatic vein divides liver into left and
• Right hepatic vein divides right lobe into anterior and posterior segments.
• A horizontal line thru left and right main portal veins is used to divide lobes into inferior and superior segments.
• The 8 liver segments are numbers clockwise on the frontal view.
• Symptoms of injury are related to blood loss, peritoneal irritation, RUQ tenderness, and guarding.
• Unrecognized delayed abcess • Bilomas • Signs of blood loss may dominate the picture.
• Elevated liver tests • Biliary peritonitis (nausea, vomiting, abd
pain). • DPL has high sensitivity, 1-2% complication
rate. • Plain x-rays non-specific. • CT scan diagnostic procedure of choice. • Hida for leaks, angio for hemorrhage.
• FAST sensitivity highest (98%) for grade 3 injuries or greater. Negative findings do not exclude hepatic injury.
• Emergency sono findings demonstrating free fluid, parenchymal injury, or both demonstrate overall sensitivity for detection of blunt abdominal trauma of 72%.
• Angiogram may fail to detect active bleeding.
• Accurate in localizing the site of liver injury, associated injuries.
• Used to monitor healing. • CT criteria for staging liver trauma uses AAST
liver injury scale • Grades 1-6 • Hematoma,laceration,vascular,acute
• I-Subcapsular hematoma<1cm, superficial laceration<1cm deep.
• II-Parenchymal laceration 1-3cm deep, subcapsular hematoma1-3 cm thick.
• III-Parenchymal laceration> 3cm deep and subcapsular hematoma> 3cm diameter.
• IV-Parenchymal/supcapsular hematoma> 10cm in diameter, lobar destruction, or devasularization.
• V- Global destruction or devascularization of the liver.
• VI-Hepatic avulsion
• Demonstrates active bleeding • Transcatheter embolization may be the only
treatment required. • Findings include contusion, laceration,
hematoma, pseudoaneurysms, fistulas. • Embolization can reduce transfusion
requirements, stenting for fistulas.