25 HEPATIC AND BILIARY TRAUMA
Reginald J. Franciose M.D., Ernest E. Moore M.D.

1. How often is the liver injured in trauma?

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The liver is both big and central, so it is an easy target.

2. Do the liver and spleen respond similarly to injury?

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No. The liver has a unique ability to establish spontaneous hemostasis even with extensive injuries. For this reason, the majority of liver injuries in hemodynamically stable patients can be managed nonoperatively. In contrast, many splenic fractures continue to bleed; therefore, a greater percentage require operative intervention.

3. What are the determinants of mortality after acute liver injury?

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The mechanism of injury and the number of associated abdominal organs injured determine mortality. The mortality for stab wounds to the liver is 2%; for gunshot wounds, 8%; and for blunt injuries, 15%. The mortality rate for isolated grade III hepatic injuries is 2%; for grade IV, 20%; and for grade V, 65%. Retrohepatic vena cava injuries carry mortality rates of 80% for penetrating trauma and 95% for blunt trauma.

4. What history and physical signs suggest acute liver injury?

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Any patient sustaining blunt abdominal trauma with hypotension must be assumed to have a liver injury until proven otherwise. Specific signs that increase the likelihood of hepatic injury are contusion over the right lower chest, fracture of the right lower ribs (especially posterior fractures of ribs 9-12), and penetrating injuries to the right lower chest (below the fourth intercostal space, flank, and upper abdomen). Physical signs of hemoperitoneum may be absent in as many as one third of patients with significant hepatic injury.

5. What diagnostic tests are helpful in confirming acute liver injury?

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A focused abdominal sonography for trauma (FAST) examination can detect or rule out hemoperitoneum and pericardial tamponade. Diagnostic peritoneal lavage (DPL) is sensitive for hemoperitoneum (99%). Ultrasound is highly sensitive in identifying > 200 mL of intraperitoneal fluid. It is noninvasive and may be repeated at frequent intervals, but it is relatively poor for staging liver injuries. Abdominal computed tomography (CT) scan currently is used only in hemodynamically stable patients who are candidates for nonoperative management. The major shortcoming of CT is the relatively poor correlation between hepatic CT staging and subsequent risk of hemorrhage.

6. What is the role of hepatic angiography and radionuclide biliary excretion scans in the diagnosis of liver injury?

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Selective hepatic artery embolization is effective therapy for hepatic arterial bleeding, both for avoidance of surgery and for recurrent postoperative bleeding.