**4. Diagnosis**

The physical stress of trauma is common in patients of liver injury, and this can cause disturbed biochemical blood test. Initial rise in white blood cell count and low red blood cell count is a nonspecific finding. The degree of anemia correlated to the volume of blood loss. Such loss can be from liver or other than the liver. Other causes include amount of crystalloids or colloids used during initial resuscitation. In posttraumatic hemorrhage, the duration and course of developing anemia is variable and as already explained related to the frequency, amount, and

**Figure 2.** Assessment of trauma patient

rapidity of exogenous fluid administration and endogenous fluid shifts. Therefore, it is important to anticipate that significant liver trauma-related bleeding can happen irrespective of the presence or absence of anemia at the time of initial patient presentation.

In the hemodynamically stable patient, diagnosis of liver injury may be suspected based upon history of mechanism of injury, findings on physical examination, or laboratory findings of blood or other body fluids [16].

Imaging, especially using computed tomography (CT) with intravenous contrast of the abdomen, confirms the injury and also helps in defining the grade of injury. The characteristic pattern of pooling of intravenous contrast in or around the liver suggests ongoing bleeding and thus warrants the need for intervention. The imaging with the help of CT scan is also useful in identifying concurrent intra-abdominal and chest injuries [2, 17, 18].

The role of FAST examination comes when patient is hemodynamically unstable. However, in cases of intraparenchymal injuries, a negative FAST examination is not sufficient to exclude liver injury. Signs of liver injury on FAST examination include the presence of a hypoechoic (black) rim of subcapsular fluid, fluid in Morrison's pouch (hepatorenal space), or intraperi‐ toneal fluid around the liver. The main objective of this investigation is quick bedside assess‐ ment for hemoperitoneum and hemopericardium. The primary utility of this investigation is identifying the presence of blood and bleeding and not the identification of or defining the degree of organ injuries [19, 20] (Table 2).


rapidity of exogenous fluid administration and endogenous fluid shifts. Therefore, it is important to anticipate that significant liver trauma-related bleeding can happen irrespective

In the hemodynamically stable patient, diagnosis of liver injury may be suspected based upon history of mechanism of injury, findings on physical examination, or laboratory findings of

Imaging, especially using computed tomography (CT) with intravenous contrast of the abdomen, confirms the injury and also helps in defining the grade of injury. The characteristic pattern of pooling of intravenous contrast in or around the liver suggests ongoing bleeding and thus warrants the need for intervention. The imaging with the help of CT scan is also useful

The role of FAST examination comes when patient is hemodynamically unstable. However, in cases of intraparenchymal injuries, a negative FAST examination is not sufficient to exclude liver injury. Signs of liver injury on FAST examination include the presence of a hypoechoic (black) rim of subcapsular fluid, fluid in Morrison's pouch (hepatorenal space), or intraperi‐ toneal fluid around the liver. The main objective of this investigation is quick bedside assess‐ ment for hemoperitoneum and hemopericardium. The primary utility of this investigation is identifying the presence of blood and bleeding and not the identification of or defining the

of the presence or absence of anemia at the time of initial patient presentation.

in identifying concurrent intra-abdominal and chest injuries [2, 17, 18].

blood or other body fluids [16].

**Figure 2.** Assessment of trauma patient

304 Recent Advances in Liver Diseases and Surgery

degree of organ injuries [19, 20] (Table 2).


**Table 2.** Value of The Focused Assessment with Sonography in Trauma (FAST)

Even if diagnostic peritoneal aspiration or lavage (DPL) has largely been replaced by the FAST examination, it may still be useful in selected patients, if the FAST is equivocal. In addition, the ATLS still includes DPL modality, and it remains one of the skills that physicians need to learn for ATLS certification. However, a recent Cochrane review has put a question mark on the reliability of ultrasonography for early diagnostic investigations in patients with suspected blunt abdominal trauma [21].

Detailed systematic abdominal ultrasound examination in the radiology suit and/or magnetic resonance imaging (MRI) is time consuming and not feasible in the setting of hemodynamic instability of trauma in the initial diagnosis of liver injury. Furthermore, it puts the patient in a location remote from trauma management area. However, MRI may be useful in a subset of hemodynamically stable patients who cannot undergo CT scan (e.g., IV contrast allergy), and patients with suspected bile ductal injury. Arteriography is generally reserved for patients who have indications for hepatic embolization to manage intrahepatic arterial hemorrhage [22, 23].

Recently, studies have tried to find out other markers that will help in grading the severity and deciding the conservative management of blunt hepatic injury. Koca et al. [24] found that liver transaminases can predict the hepatic injury with higher accuracy as the grade rises, and it can be superior to FAST in terms of determining the need for laparotomy.

Out of multiple modalities available for evaluating stable patients, CT scan along with hemodynamic stability are best in evaluating which patient requires surgery or in deciding which patient can be safely discharged from emergency. The main drawbacks of CT scan are its cost, low sensitivity in detecting bowel injuries, and hemodynamically unstable patients [1]. In

Table 3 some important summary points regarding investigation of blunt abdominal trauma [25].

**Table 3.** Investigation of blunt abdominal trauma: key points

<sup>⋅</sup> The diagnosis of abdominal injury by clinical examination alone is unreliable

<sup>⋅</sup> FAST is the investigation of choice in hemodynamically unstable trauma victim

<sup>⋅</sup> CT scan with IV contrast is the investigation of choice in hemodynamically stable trauma victim

<sup>⋅</sup> Solid organ injury in hemodynamically stable patients with no associated injuries (requiring urgent surgery) can often be managed without surgery
