Introduction:
The one organ that is often and most regularly injured, especially due to blunt trauma in the body, is the liver. As the liver is a large organ occupying a major size in the abdominal cavity, it is also more prone to get stab or penetrating injuries. The liver, as an organ, has a large structure but is covered by thin blood vessels showing high blood flow. The trauma to the liver can run a course from mild lacerations to major extensive injuries leading to minimal morbidity rates and the avulsion of the hepatic tissues leading to high mortality rates. In most cases, the hepatic injuries are minor and are classified according to the level of trauma by the American Association for the Surgery of trauma hepatic injury scale. Minimally invasive procedures are used to treat minor injuries, and in case of major injuries, resuscitation of the liver, along with surgical intervention and damage control, is seen.
What Causes Liver Trauma?
Injury to the liver is commonly occurring in blunt and stab abdominal injuries. This mainly occurs due to the location of the liver in the abdomen, making the liver parenchyma and Gleeson’s capsule more fragile and prone to injury. In addition, the fixed position of the liver also makes it more susceptible to laceration injuries due to shear forces. The reasons for abdominal trauma are mostly due to accidents that include vehicle, and pedestrian fall injuries, gunshot injuries, etc. Due to its position, the right lobe of the liver is more commonly injured than the left.
How Commonly Is Liver Trauma Seen?
Among all the trauma cases, liver trauma compromises almost five percent. Liver trauma is a very commonly injured organ, but it is often associated with other injuries. Liver injuries are graded from one to four, and the death rate rises with the increase in the grading. Minor liver injuries generally make up eighty to ninety percent of the cases and come under grade one or two, whereas injuries under grade four are often fatal. Death due to liver injury is a major cause of abdominal trauma cases and has a death rate of ten to fifteen percent.
How Is Liver Trauma Clinically Seen?
The provision of care for patients with injury to the liver begins soon after trauma. The patients showing symptoms of liver trauma are clinically seen as:
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Severe abdominal pain.
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The patient was seen to hold the abdomen (guarding position).
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Tenderness on palpation in the right upper side of the abdomen.
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Radiating pain in the right shoulder.
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Symptoms of shock.
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Increased loss of blood.
How Is Liver Trauma Evaluated?
As the liver is an organ of multifactorial function, various tests are taken to assess the proper functioning of the liver, and they are:
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Laboratory Evaluation: All patients with a history of liver trauma have a series of standardized laboratory tests required to assess the liver’s function. Thelaboratorian tests include a comprehensive metabolic assay, total blood count, bleeding and clotting time, and serum lactate levels. In addition to all these tests, a liver function test is prescribed, but the liver function test remains abnormal from the onset of the injury up to a few days.
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Radiological Evaluation: Radiological procedures are used to treat liver injuries occurring due to trauma. The standard radiological tests include:
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Focus Assessment Test with Sonography for Trauma (FAST) Examination: This test is used to know the presence of blood in the abdominal cavity or the pericardial sac surrounding the heart. However, it does not identify the intensity of organ injury. The FAST test usually depends on the operator, and the specificity of the results generally ranges from 63 percent to 100 percent.
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Computed Tomography: This is a three-dimensional imaging method used for identifying the level of liver injury and its grading. The CT scan of the abdomen is taken by injecting a dye contrast intravenously. This helps identify the tear in the organ or blood loss more evidently.
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Magnetic Resonance Cholangiopancreatography (MRCP): This is a very uncommon test but is usually preferred to identify the bile duct injury or a leak.
How Is Liver Trauma Treated?
The treatment of liver trauma can be done in three ways depending on their severity, and they are:
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Non-operative Management: Non-operative management is preferred in cases where the patient is potentially stable according to the regulation criteria framed by the eastern association for trauma surgery. Nonoperative therapy mainly concentrates on monitoring blood levels, abdominal examinations, and having an operating room on hold for emergency purposes. Patients with high-grade injuries usually do not reciprocate the non-operative treatment positively, leading to treatment failure in almost 75 % of cases.
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Angiographic Embolization: Angiography and embolization procedure (a procedure done to test the blood vessels or bleeding spots along with a balloon-like catheter) is a selective and effective treatment for patients undergoing non-operative therapy. The success rate of this treatment is usually 83 %.
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Operative Management: Surgical management is preferred in severely unstable patients. There are four important processes to establish while performing this procedure: controlling blood loss, preventing and controlling contamination of the gastrointestinal tract, localizing the injury, and damage control. In case of excessive bleeding, a pringle maneuver is performed (a procedure that helps the surgeon to stop the bleeding and to find the source of origin, enabling it to repair the blood vessels in severely catastrophic injuries, ligation of the hepatic artery, and removal of the liver lobe). However, care should be taken to ensure the portal vein (the vein that drains blood from the spleen to the liver) is intact.
What Are the Complications Associated With Liver Trauma?
The complications of trauma to the liver include:
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Bile leak (a common condition).
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Development of abscess in the liver.
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Necrosis of the liver.
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Hemobilia (a clinical condition characterized by bleeding of or from the biliary tract).
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Bleeding in the gastrointestinal tract.
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Pain in the abdomen.
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Jaundice.
What Are the Conditions That Appear Similar to Liver Trauma?
The clinical conditions that appear similar to liver trauma and need to be differentiated are:
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Hypovolemic shock - It is an emergency clinical condition occurring due to insufficiency of blood in the system after severe blood loss where the heart struggles to pump adequate blood to all parts of the body.
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Pregnancy trauma.
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Upper or lower genitourinary trauma.
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Domestic violence.
Conclusion:
The liver is the most vital organ of the body. But, injury to the liver can be very common, ranging from minor falls to major injuries. It is important to identify and treat it at a very appropriate time to prevent further complications. Liver trauma involves a multidisciplinary approach and requires a continuous healing period. Patients show good recovery in grade one and grade two injuries with a few years of healing.
