**2. Etiology of liver trauma**

The liver can be injured commonly by the following:


#### **2.1. Diagnosis of liver trauma**


#### **Obvious liver trauma:**

Liver injury can be positively diagnosed where the following points are clearly established:

*2.1.2. B: Investigations*

*2.1.2.1. Routine investigations*

loss where the injury is severe.

*2.1.2.2. Imaging investigations*

specific and not done to look for liver injury.

**Figure 1.** CT scan for a patient with massive liver trauma.

transainase (GOT) and alkaline phosphatase (ALK) phos.

Blood group is done routinely in all patients with hepatic trauma.

performed by expert, but nowadays, it is replaced by ultrasound scan.

Routine examination includes full blood count, electrolytes, blood sugar, urea, hemoglobin may be normal where the injury is simple, or there may be low hemoglobin indicating blood

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Liver function tests were not done at the admission time and may not be needed if the injury is simple; it could be done if the case showed severe liver trauma. Liver function includes bilirubin, and liver enzymes include glutamic pyruvate transaminase (GPT), glutamic oxaloacetate

Ultrasound scan for liver trauma has 99% of specificity and 88% of sensitivity [19–21]. Fast ultrasound replaced peritoneal lavage. Looking to Morrison space if there is fluid in the space indicating bleeding. The use of contrast with ultrasound scan is more beneficial in liver trauma. **CT scan**: This is done on a stable patient with oral and intravenous contrast. CT scan for liver injury has more than 90% of sensitivity and specificity (**Figure 1**). Useful for diagnosis of liver injury and follow-up of liver trauma, for any hemorrhage, bile accumulation or sepsis.

**X-ray**: X-ray chest may show fractured ribs at the site of the liver from 7th to 9th rib but is not

**DPL Diagnostic peritoneal lavage**: This is an invasive procedure done on patients with trauma when there is intraperitoneal bleeding. It is useful and produces good results when


#### **Liver trauma can be easily predicted with the following points borne in mind:**


#### **Liver trauma is difficult to predict:**

**1.** Normal blood pressure with right upper abdominal pain with guarding and tenderness at the right upper quadrant

#### **Clinical presentation of liver trauma:**


#### Grading of liver trauma: **American association of trauma**

Grade I: Subcapsular haematoma less than 10% of the surface area. Laceration less than 1 cm.

Grade II: Haematoma more than 10–50% surface area. Laceration from 1 to 3 cm.

Grade III: Haematoma more than 50%. Laceration more than 3 cm.

Grade IV: Ruptured haematoma and bleeding. Laceration of the liver from 25 to 75% of the lobe.

Grade V: More than 75% of liver laceration, retrohepatic vena cava injury or hepatic vein injuries.

Grade VI: Hepatic avulsion.

#### *2.1.2. B: Investigations*

**Obvious liver trauma:**

100 Liver Research and Clinical Management

a road traffic accident.

**Liver trauma is difficult to predict:**

**Clinical presentation of liver trauma:**

**1.** Pain at the right upper quadrant.

the right upper quadrant

**2.** Fracture of right lower ribs.

Grade VI: Hepatic avulsion.

**3.** Shock

lobe.

injuries.

the trauma.

Liver injury can be positively diagnosed where the following points are clearly established:

**1.** The patient is in a state of shock where he or she was involved in a road traffic accident or

**2.** The patient is with hypotension and pain at the right upper quadrant of the abdomen after

**3.** Hypotensive patient shows tenderness over the right side of chest with fractured ribs after

**1.** Drop in blood pressure in a patient with road traffic accident and with guarding and ten-

**1.** Normal blood pressure with right upper abdominal pain with guarding and tenderness at

Grade I: Subcapsular haematoma less than 10% of the surface area. Laceration less than 1 cm.

Grade IV: Ruptured haematoma and bleeding. Laceration of the liver from 25 to 75% of the

Grade V: More than 75% of liver laceration, retrohepatic vena cava injury or hepatic vein

Grade II: Haematoma more than 10–50% surface area. Laceration from 1 to 3 cm.

hit by a bullet at the right upper quadrant of the abdomen.

**4.** Hypotensive patient with bruises at the right upper quadrant.

**2.** Penetrating wound at the right upper quadrant of the abdomen.

derness at the right side of the upper abdomen.

Grading of liver trauma: **American association of trauma**

Grade III: Haematoma more than 50%. Laceration more than 3 cm.

**Liver trauma can be easily predicted with the following points borne in mind:**

#### *2.1.2.1. Routine investigations*

Routine examination includes full blood count, electrolytes, blood sugar, urea, hemoglobin may be normal where the injury is simple, or there may be low hemoglobin indicating blood loss where the injury is severe.

Liver function tests were not done at the admission time and may not be needed if the injury is simple; it could be done if the case showed severe liver trauma. Liver function includes bilirubin, and liver enzymes include glutamic pyruvate transaminase (GPT), glutamic oxaloacetate transainase (GOT) and alkaline phosphatase (ALK) phos.

Blood group is done routinely in all patients with hepatic trauma.

#### *2.1.2.2. Imaging investigations*

Ultrasound scan for liver trauma has 99% of specificity and 88% of sensitivity [19–21]. Fast ultrasound replaced peritoneal lavage. Looking to Morrison space if there is fluid in the space indicating bleeding. The use of contrast with ultrasound scan is more beneficial in liver trauma.

**CT scan**: This is done on a stable patient with oral and intravenous contrast. CT scan for liver injury has more than 90% of sensitivity and specificity (**Figure 1**). Useful for diagnosis of liver injury and follow-up of liver trauma, for any hemorrhage, bile accumulation or sepsis.

**X-ray**: X-ray chest may show fractured ribs at the site of the liver from 7th to 9th rib but is not specific and not done to look for liver injury.

**DPL Diagnostic peritoneal lavage**: This is an invasive procedure done on patients with trauma when there is intraperitoneal bleeding. It is useful and produces good results when performed by expert, but nowadays, it is replaced by ultrasound scan.

**Figure 1.** CT scan for a patient with massive liver trauma.

#### **2.2. Treatment of liver trauma**

**Table 1** shows the number and types of liver trauma treated using different treatments in a busy general hospital.

*2.2.1. Conservative treatment of liver trauma*

**1.** Full assessment of patients.

**4.** Daily monitoring of patient.

of injury [2, 16].

*2.2.3. Advantages of NOM*

**1.** Less hospital stay.

managed conservatively without surgery [3, 11, 15, 18].

**5.** Discharge of patient once he is fully stable and active.

**6.** Post-discharge follow-up by clinical assessment and imaging.

**2.** Full assessment of the grade of liver injury by ultrasound and CT scan.

Conservative treatment includes the following:

**3.** Correction of blood loss by giving blood.

*2.2.2. Non-operative treatment of liver injury*

**2.** Avoidance of unnecessary laparotomy.

An unstable patient can be defined as follows:

**1.** Systolic blood pressure less than 90 mmhg. **2.** Pulse rate more than 120 beats per minute.

dynamically stable. It can be utilized even in grade IV.

Non-operative treatment can be performed for the following reasons:

**2.** Operative management should be available when needed.

**1.** Patients who are haemodynamically stable with no signs of peritonism.

**3.** Altered consciousness level.

**4.** Altered breathing. **5.** Cold clammy skin.

Blunt liver trauma can be mild, moderate or severe. Mild and moderate liver trauma can be

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Non operative management was firstly conducted in children than started in adult, it is not indicated in elderly patients, choosing of the patients for non-operative management (NOM) depends on clinical condition of the patients and associated injury, less on grade of the liver

About 80% of blunt liver trauma can be treated conservatively, provided the patient is haemo-

Eighty percent of adults with liver trauma were treated conservatively, and 97% of those were children who were treated conservatively.

Healing of liver trauma: The liver has good capacity of healing once it is traumatized.

Mild liver trauma: Less than 25% of lobe damage takes 3 months to heal.

Moderate liver trauma: Between 25 and 50% takes 6 months to heal.

Severe injury: Liver injury, which encompasses more than 50% of lobe injured, takes 9 months to heal or more.

Patients with liver trauma blunt or penetrating, mild or severe once diagnosed or suspected should undergo resuscitation as usual traumatized patients, which include caring of respiration, putting good venous access for the fluids, treating emergency killing conditions like tension pneumothorax, fixing urinary catheter to know the output. After patient resuscitation, the grading of liver trauma is evaluated clinically and by imaging and the mode of treatment is planned which will include either [8–10].



**Table 1.** Different types of hepatic trauma patients who were treated at Zliten teaching hospital.

#### *2.2.1. Conservative treatment of liver trauma*

Blunt liver trauma can be mild, moderate or severe. Mild and moderate liver trauma can be managed conservatively without surgery [3, 11, 15, 18].

Conservative treatment includes the following:

**1.** Full assessment of patients.

**2.2. Treatment of liver trauma**

102 Liver Research and Clinical Management

children who were treated conservatively.

is planned which will include either [8–10].

and right lobe

Right lobe

and right lobe

**3.** Interventional radiology treatment of liver trauma.

Range from grade I

Grade I and II had few patients, and most were

**Table 1.** Different types of hepatic trauma patients who were treated at Zliten teaching hospital.

grade III, IV

to VI

**1.** Non-operative treatment.

**2.** Operative treatment.

RTA 94 Left lobe

Bullet 124 Left lobe

Stab 13 Left lobe

**Mode Number of patients**

busy general hospital.

to heal or more.

**Table 1** shows the number and types of liver trauma treated using different treatments in a

Eighty percent of adults with liver trauma were treated conservatively, and 97% of those were

Severe injury: Liver injury, which encompasses more than 50% of lobe injured, takes 9 months

Patients with liver trauma blunt or penetrating, mild or severe once diagnosed or suspected should undergo resuscitation as usual traumatized patients, which include caring of respiration, putting good venous access for the fluids, treating emergency killing conditions like tension pneumothorax, fixing urinary catheter to know the output. After patient resuscitation, the grading of liver trauma is evaluated clinically and by imaging and the mode of treatment

**Lobe Grade Procedure Outcome**

and insertion of drain 3. Laparotomy: 47

liver resection

I and II Conservative management Nil

1. Conservative treatment: 35 cases 2. Diagnostic laparoscopy: 12 suturing 13 died

18 died

3-A. Repair of liver wounds: 30 3-B. Packing: 14 perihepatic packing 3-C. Resection: Three had segmental

All underwent laparotomy,

debridement, repair, omental packing, eight patients had perihepatic packing

Healing of liver trauma: The liver has good capacity of healing once it is traumatized.

Mild liver trauma: Less than 25% of lobe damage takes 3 months to heal.

Moderate liver trauma: Between 25 and 50% takes 6 months to heal.


#### *2.2.2. Non-operative treatment of liver injury*

Non operative management was firstly conducted in children than started in adult, it is not indicated in elderly patients, choosing of the patients for non-operative management (NOM) depends on clinical condition of the patients and associated injury, less on grade of the liver of injury [2, 16].

#### *2.2.3. Advantages of NOM*


An unstable patient can be defined as follows:


About 80% of blunt liver trauma can be treated conservatively, provided the patient is haemodynamically stable. It can be utilized even in grade IV.

Non-operative treatment can be performed for the following reasons:


**3.** Imaging facilities should be available to follow the treatments, which can lead to 100% success rate.

**Surgical procedures** (**Figure 4** shows different repair of liver trauma).

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**2.** Debridment of unhealthy liver tissue and suturing.

**4.** Liver lobectomy or hepatectomy for severely damaged lobe.

**Figure 2.** CT abdomen of a child who had liver trauma and was treated conservatively developed bile collection as a

**3.** Resection of severely damaged segment.

**1.** Simple suturing of liver tear.

complication of hepatic trauma management.

Liver trauma at Zliten University Hospital over a period of 9 years from 2009 to 2017— Patients: 231, deaths: 31, patients who underwent conservative treatment: 48 (**Table 1**).

Most of our patients with liver trauma during war, the time where the weapon is scattered in many regions of the country; none of our patients with hepatic trauma having had gun shot wounds left for conservative treatment, and all patients underwent surgery. This number affected our conservative management in hepatic trauma. Our rate of conservative treatment for patients with hepatic trauma was approximately 50%.

#### *2.2.4. Complications of NOM*

Complications of NOM can be diagnosed by clinical examination including blood tests, ultrasound scan and CT scan. Complications may reach up to 7% in grade III and V.

**1.** Bile collection may reach up to 20%—biliary peritonitis. Haemobilia: Bile leak is treated with endoscopic retrograde cholangiopancreatography most of our patients with liver trauma were during war. If fluid collection is significant, it can be drained percutaneously, laparoscopically or open surgery. **Figure 2** shows the CT of a child with hepatic trauma managed conservatively with the development of bilioma). **Figure 3** shows bilioma collection that was treated by laparotomy.

Nagano-classified bile leak:

Type A: Minor bile leak, small radicle from the liver surface—resolved spontaneously.

Type B: Bile leak from a major duct on the liver surface not tied.

Type C: Injury of duct branch from the main duct at the hilum.

Type D: Main bile duct transected.


#### *2.2.5. Surgical treatment of liver injury*


**Surgical procedures** (**Figure 4** shows different repair of liver trauma).

**1.** Simple suturing of liver tear.

**3.** Imaging facilities should be available to follow the treatments, which can lead to 100%

Liver trauma at Zliten University Hospital over a period of 9 years from 2009 to 2017— Patients: 231, deaths: 31, patients who underwent conservative treatment: 48 (**Table 1**).

Most of our patients with liver trauma during war, the time where the weapon is scattered in many regions of the country; none of our patients with hepatic trauma having had gun shot wounds left for conservative treatment, and all patients underwent surgery. This number affected our conservative management in hepatic trauma. Our rate of conservative treatment

Complications of NOM can be diagnosed by clinical examination including blood tests, ultra-

**1.** Bile collection may reach up to 20%—biliary peritonitis. Haemobilia: Bile leak is treated with endoscopic retrograde cholangiopancreatography most of our patients with liver trauma were during war. If fluid collection is significant, it can be drained percutaneously, laparoscopically or open surgery. **Figure 2** shows the CT of a child with hepatic trauma managed conservatively with the development of bilioma). **Figure 3** shows bilioma collec-

Type A: Minor bile leak, small radicle from the liver surface—resolved spontaneously.

**2.** Infection and abscess formation may reach 7% and can be treated conservatively when

**3.** Liver necrosis can be diagnosed clinically with raised liver enzymes, coagulation abnor-

**4.** Bleeding: Hepatic artery pseudo-aneurysm accounts to about 1–2% and can be either extrahepatic or intrahepatic—more cases of extrahepatic nature. Liver compartment syndrome due to compression of the liver by huge subcapsular haematoma may result in liver failure.

**2.** Surgical treatment is indicated if the patient was on conservative treatment and showed

sound scan and CT scan. Complications may reach up to 7% in grade III and V.

Type B: Bile leak from a major duct on the liver surface not tied. Type C: Injury of duct branch from the main duct at the hilum.

for patients with hepatic trauma was approximately 50%.

success rate.

104 Liver Research and Clinical Management

*2.2.4. Complications of NOM*

tion that was treated by laparotomy.

Type D: Main bile duct transected.

clinical manifestation is significant.

*2.2.5. Surgical treatment of liver injury*

signs of deterioration, [8, 27–29].

**1.** Surgery is indicated in a patient who is unstable.

malities or bile leak.

Nagano-classified bile leak:


**Figure 2.** CT abdomen of a child who had liver trauma and was treated conservatively developed bile collection as a complication of hepatic trauma management.

Phase I: Control of bleeding, closure of the abdomen.

Phase III: Re-exploration of the abdomen.

**Complication of perihepatic packing:**

**1.** Compartment syndrome.

The complication of perihepatic packing includes the following:

**3.** Abdominal sepsis if the packs were left longer than 3 days.

**2.** Respiratory embarrassment due to compression on the right dome of the diaphragm.

coagulability.

M. Stewart).

antibiotics.

Phase II: Intensive care unit resuscitation and overcome on acidosis, hypothermia, hyper-

**Figure 4.** Liver trauma repaired and the wound packed with omentum (taken with permission from Prof. Ronald

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In 1983, Stone et al. proposed damage control for trauma patient [6, 14, 22–24]. Once patient had severe liver trauma, where the condition of the patient is deteriorating during surgery and the bleeding is continuous from the damaged liver, either the damage at the posterior aspect or whole of the liver, damage control is utilized in the form of packing the liver with abdominal gauze pack which are wrapped around the liver [4–6]. This technique is useful in the management of controlling the bleeding that occurs during surgery and liver resection. Packing is also useful to avoid the three killers of the patient during surgery which includes acidosis, hypercoagulability and hypothermia, which can cause cardiac arrest. To avoid the occurrence of these bad incidents, we should change to damage control. Usually six packs are placed around the liver to stop the bleeding. The abdomen left either open or closed depending on the patient's condition with the use of Bogota bag. Packing the liver with gauze packs can be complicated when patients need to go through full resuscitation in the ICU. For the correction of the three killers including acidosis, hyperthermia, hypercoagulability, usually it needs time for our patients 48–72 h to control sepsis with the use of

**Figure 3.** Child who had liver trauma managed conservatively and complicated by bile leak, presented with encysted bilioma. The child underwent laparotomy.[13].


#### **Damage control in liver trauma:**

Damage control is of three phases:

**Figure 4.** Liver trauma repaired and the wound packed with omentum (taken with permission from Prof. Ronald M. Stewart).

Phase I: Control of bleeding, closure of the abdomen.

Phase II: Intensive care unit resuscitation and overcome on acidosis, hypothermia, hypercoagulability.

Phase III: Re-exploration of the abdomen.

In 1983, Stone et al. proposed damage control for trauma patient [6, 14, 22–24]. Once patient had severe liver trauma, where the condition of the patient is deteriorating during surgery and the bleeding is continuous from the damaged liver, either the damage at the posterior aspect or whole of the liver, damage control is utilized in the form of packing the liver with abdominal gauze pack which are wrapped around the liver [4–6]. This technique is useful in the management of controlling the bleeding that occurs during surgery and liver resection. Packing is also useful to avoid the three killers of the patient during surgery which includes acidosis, hypercoagulability and hypothermia, which can cause cardiac arrest. To avoid the occurrence of these bad incidents, we should change to damage control. Usually six packs are placed around the liver to stop the bleeding. The abdomen left either open or closed depending on the patient's condition with the use of Bogota bag. Packing the liver with gauze packs can be complicated when patients need to go through full resuscitation in the ICU. For the correction of the three killers including acidosis, hyperthermia, hypercoagulability, usually it needs time for our patients 48–72 h to control sepsis with the use of antibiotics.

#### **Complication of perihepatic packing:**

The complication of perihepatic packing includes the following:

**1.** Compartment syndrome.

**5.** Perihepatic packing for uncontrolled bleeding in unstable patients.

surgery [17].

**Damage control in liver trauma:** Damage control is of three phases:

bilioma. The child underwent laparotomy.[13].

106 Liver Research and Clinical Management

**6.** Arterial embolization which can be performed as the first option in patients who are planned for non-operative treatment or for those patient who developed bleeding after

**Figure 3.** Child who had liver trauma managed conservatively and complicated by bile leak, presented with encysted


Other surgical procedure for liver trauma include


[2] Li M, Yu WK, Wang XB, Ji W, Li JS. Non-operative management of isolated liver trauma.

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[3] Letoublon C, Amariutei A, Taton N, Lacaze L, Abba J, Risse O, Arvieux C. Management of blunt hepatic trauma. Journal of Visceral Surgery. 2016 Aug;**153**(4 Suppl):33-43. DOI:

[4] Ng N, McLean SF, Ghaleb MR, Tyroch A. Hepatic "BOLSA" a novel method of perihepatic wrapping for hepatic hemorrhage "BOLSA". International Journal of Surgery Case

[5] Stassen NA, Bhullar I, Cheng JD, Crandall M, Friese R, Guillamondegui O, Jawa R, Maung A, Rohs TJ Jr, Sangosanya A, Schuster K, Seamon M, Tchorz KM, Zarzuar BL, Kerwin A. Nonoperative management of blunt hepatic injury: An Eastern Association for the Surgery of Trauma practice management guideline. Journal of Trauma and Acute

[6] Lin BC, Fang JF, Chen RJ, Wong YC, Hsu YP. Surgical management and outcome of blunt major liver injuries: Experience of damage controllaparotomy with perihepatic packing in one trauma centre. Injury. 2014 Jan;**45**(1):122-127. DOI: 10.1016/j.injury.2013.08.022

[7] Schnüriger B, Inderbitzin D, Schafer M, Kickuth R, Exadaktylos A, Candinas D. Concomitant injuries are an important determinant of outcome of high-grade blunt hepatic trauma. The British Journal of Surgery. 2009 Jan;**96**(1):104-110. DOI: 10.1002/bjs.6439

[8] Girgin S, Gedik E, Taçyildiz IH. Evaluation of surgical methods in patients with blunt

[9] Gür S, Orsel A, Atahan K, Hökmez A, Tarcan E. Surgical treatment of liver trauma (analysis of 244 patients). Hepato-Gastroenterology. 2003 Nov-Dec;**50**(54):2109-2111

[10] Terrinoni V, Catroppo JF, Caramanico L, Cosimati A, Cosimati P, Bellini N, Abate O, Rengo M. The diagnostic-therapeutic picture in liver injuries: A review of the literature

[11] Buci S, Torba M, Gjata A, Kajo I, Bushi G, Kagjini K. The rate of success of the conservative management of liver trauma in a developing country. World Journal of Emergency

[12] Lim KH, Chung BS, Kim JY, Kim SS. Laparoscopic surgery in abdominal trauma: A single center review of a 7-year experience. World Journal of Emergency Surgery. 2015;**10**:16

[13] Giss SR, Dobrilovic N, Brown RL, Garcia VF. Complications of nonoperative management of pediatric blunt hepatic injury: Diagnosis, management, and outcomes. The

[14] Kobayashi T, Kubota M, Arai Y, Ohyama T, Yokota N, Miura K, Ishikawa H, Soma D, Takizawa K, Sakata J, Nagahashi M, Kameyama H, Wakai T. Staged laparotomies based on the damage control principle to treat hemodynamically unstable grade IV blunt

hepatic injury in an eight-year-old girl. Surgical Case Reports. 2016 Dec;**2**:134

liver trauma. Ulusal Travma ve Acil Cerrahi Dergisi. 2006 Jan;**12**(1):35-42

and clinical cases. Il Giornale di Chirurgia. 1995 Jan-Feb;**16**(1-2):48-54

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10.1016/j.jviscsurg.2016.07.005

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**3.** Liver exclusion and extracorporeal circulation is seldom done for severe liver trauma.

Controlling of liver bleeding: Bleeding from the liver is controlled by the following procedures


Mortality of blunt trauma is 27% and of penetrating trauma is 11%.

Overall, mortality of liver trauma is 10%, Grade III and IV mortality is 10% and V and VI are 75%.

There are many haemostatic materials used for liver trauma are very helpful for controlling the bleeding, which includes the following:

