45. Liver. Injuries to the liver and bile ducts

Question 1

Injuries to the liver

Anatomy of Liver:

Answer 1

• In right hypochondriac + epigastric region
• Liver divided by falciform ligament (fold of mesentery) into large right lobe + similar left lobe
• Falciform lig extends superiorly becoming coronary lig which lies on superior border of liver – helping to suspend liver into ab cavity from diaphragm
• In free border of falciform lig is the ligamentum teres (round lig (obliterated umbilical vein))
• This fibrous cord extends from liver to umbilicus
• Blood supply = hepatic artery + hepatic portal vein

Question 2

Injuries to the liver - Portal anastomosis:

Answer 2

o left gastric vein – azygous vein – Esophageal varices

o sup rectal veins – mid + inf rectal vein – haemorrhoids

o paraumbilical veins – superficial epigastric – caput medusa

Question 3

Injuries to the liver - Most common cause

Answer 3

blunt ab trauma due to motor vehicle accidents

Blunt trauma may be associated with hepatic parenchymal emboli to the right heart + lung causing death and Infarction of liver tissue

Question 4

Injuries to the liver - classification

Answer 4

1. Transcapular injury: when rupture of liver has involved Glisson’s capsule, blood + bile in peritoneal cavity
2. Sub scapular: Glisson’s capsule intact, blood collected deep to capsule, found on superior surface of organ
   a. Haematoma – can be infx = abscess
3. Central injury: interruption of the parenchyma of liver

Question 5

Injuries to the liver - Transcapular injury - Clinical Presentation

Answer 5

biliary leakage = biliary peritonitis

Question 6

Injuries to the liver - Haemorrhage

Answer 6

most imp cause of death in injury to liver

Hepatorenal synd: damaged liver cells – kidney – are toxic to kidney to destroy kidney cells

Question 7

Injuries to the liver- Classification 2

Answer 7

AAST

Grade 1: Hematoma: subscapular = <10%
Laceration: capsular tear = <1cm

Grade 2: Hematoma: subscapular = 10-50%
Laceration: tear = <1-3cm

Grade 3: Hematoma = <50%
Laceration = >3cm

Grade 4: Laceration: parenchymal disruption 25-75%

Grade 5: Laceration: parenchymal disruption >75%

Grade 6: Hepatic avulsion

Question 8

Injuries to the liver - Diagnostic investigations

Answer 8

plain AXR (fluid in peritoneum)

CT

angiography (for hematobilin – blood in bile ducts)

Question 9

Injuries to the liver - Treatment

Answer 9

conservative for haemodynamically stable pts

• For those not = surgery
  o Control bleeding – ligate vessels + removal of necrotic tissue

o Debridement of dead liver tissue – as this can lead to infx

o Tear = suture

• Major liver injury where it is difficult to control bleeding – Pringle manoeuvre used (clamping hepatoduodenal lig)

o Vascular inflam to liver is blocked – now can ligate vessels + remove dead tissue

 Push, Pringle, Plug (stop bleeding), Pack

Question 10

Injury to GB

Answer 10

Uncommon. Penetrating injuries due to gunshot wound/stab.

Non-penetrating: contusion, avulsion, laceration, rapture, traumatic cholecystitis

Question 11

Injury to GB - Treatment

Answer 11

cholecystectomy

Question 12

Extrahepatic bile ducts Injury

Answer 12

Majority: iatrogenic factors during cholecystectomies esp laparoscopic as decreased view

or

during gastrocitomy when mobilisation of duodenum is required

Question 13

Extrahepatic bile ducts Injury - Diagnostic Investigations

Answer 13

intra op bile leak + abnormal cholangiogram.

CT

US – increased LFTs

Question 14

Extrahepatic bile ducts Injury - Treatment

Answer 14

small injury = T. tube