Liver

Question 1

Liver Trauma is

Answer 1

The second common solid abdominal organ to be injured after spleen (both account for 75% of blunt injuries)

Question 2

predisposing factors for Liver Trauma

Answer 2

-Liver enlarqement: which makes it more liable to trauma. -Diseases of the Liver: which make it soft.

Question 3

Etiology of liver trauma

Answer 3

Trauma, which may be: .1- Closed: -Direct trauma: blunt trauma: e.g. motor car accident & falling from a height. -lndirect trauma: fracture ribs. -Spontaneous rupture: with pathological liver. 2- Open: -Gun-shot wounds. -Puncture due to stabbing. -latrogenic: e.g. PTC or liver biopsy

Question 4

Pathology

Answer 4

Types of ruptured liver: -Subcapsular hematoma -Superficial tear(s) -Deep tear(s) -Avulsion of a pole of the liver -Complete depulping of the liver -Injury of a vascular pedicle The most difficult injury is that of main hepatic veins because of difficult access -Hemobilia.

Question 5

Complications

Answer 5

1. Hemorrhage: (either internal or external) - lntraperitoneal hemorrhage can lead to shock. - Sub-capsular hematoma which may be infected leading to an abscess or hemobilia. 2. lnfarction of liver tissues due to occlusion of liver blood supply by hematoma or abscess. 3. Billiary leakage leading to billiary peritonitis with subsequent abscess or cyst. 4. Associated abdominal or thoracic injuries.

Question 6

Clinical Picture

Answer 6

-History: a. History of trauma to the upper abdomen or lower chest followed by abdominal pain. -General Examination (picture of hypovolemic shock): b. Rapid weak pulse, hypotension & subnormal temperature. c. Cold extremities & pallor. -Local Examination l-lnspection: - Bruises in the Rt. hypochondrium. - Fracture of the Rt. Iower ribs. - Rigidity. 2-palpation: - Tenderness & guarding in the Rt. hypochondrium. Later becomes generalized. - Rebound tenderness 3- Percussion: Shifting dullness. 4-Auscultation: dec intestinal sounds 5- DRE Fullness in the rectovesical pouch & Douglas pouch

Question 7

Investigations

Answer 7

1-Radiological: *U/S and CT scan: -Diagnostic -+ free blood in peritoneum & hematoma on the ruptured liver. -Show pathological types and injuries to other organs. *Plain X- rav: -Fracture ribs. -Elevated Rt. copula of the diaphragm. -Obliterated psoas shadow. -Multiple fluid levels. -Giant fluid level due to peritoneal collections. 2-Instrumental: -Selective hepatic angioqraphv : may be helpful, -Diaqnostic peritoneal lavaqe (DPL). 3-Laboratory Investigations: -KFTs, LFTS, FBS, electrolytes,CBC.

Question 8

Prognosis

Answer 8

• Mortality rate of liver injury = 15 - 20 %.Rise to 7O % if three organs are injured.

Question 9

Treatment

Answer 9

• Management of polytraumatized patient (advanced trauma life support) 1. Prehospital management ABCD 2. Hospital management a- Primary survey: ABCD b- Secondary survey: - Head to toe examination. - Resuscitation & monitoring. - History. - lnvestigations 3. Preoperative Preparation . Blood transfusion and morphia. 4. lmmediate Laparotomy -Adequate exposure of abdomen by longitudinal incision that can be extended in the chest. -Svstematic exploration of the abdomen. *The priority is to arrest bleeding: -lf the bleeding stops by the time of exploration , just put a drain -We control the liver hemorrhage by a combination of temporary packing of the bleeding area and application of the Pringle’s manoeuvreM which is application of a vascular clamp to the free border of lesser omentum or holding it between 2 fingers (to occlude the hepatic artery and podal vein) for 20 minutes (failed Pringle’s manoeuvre is due to hepatic vein bleeding) + fresh frozen plasma *dealing with different types of injury - Suturinq liver tears should be avoided (whenever possible) as it may cause a hematoma ) infection or hemobilia. - However: in case of deep tears, we can not stop bleeding without suturing; in this case deeply placed mattress sutures supported by a pad of omentum is recommended. - lf there is hematoma: we ligate damaged vessels and ducts and excise dead tissues. - Firm packinq of difficult and inaccessible areas eq: with hepatic veins it may be the only method for temporary arrest of bleeding *Multiple intraperitoneal drains: to avoid collections of blood and bile. *prophylactic antibiotic