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History

Basic data:




*
45
Admission date: 2007/09/12
Chief complaint:
diffuse abdominal pain after traffic accident

Present illness:


On Sep. 12 about 21:40, he drove a car and hit


against traffic island. According to the first aider,
there was alcoholic odor on his body and blood in
his oral and nasal cavity. There was no open
wound and active bleeding in appearance.

PE:




TPR: 35.2 / 80 / 18 ; BP: 92/63 mmHg


Consciousness: E3M6V5, drowsy
Abdomen: soft and distension, diffuse tenderness,
rebounding pain(+), hypoactive bowel sound

Lab Data:





Bedside abdominal echo:




Blood gas: pH=7.295, pCO2=32.6, HCO3=15.4,


pO2=57.1, ABEc=-9.7, SBEc=-9.8
GOT/GPT= 297/230,
U/A: OB=2+
No fluid seen

Abdominal CT:

Impression: liver laceration, grade IV

Treatment:
Sep. 13th, 2:35AM hepatorrhaphy + repair of
portal vein and hepatic vein
liver laceration of S4~S7
 Sep. 13th, 9:50AM Partial segmentectomy
(S4~S6)


Died on Sep. 14th, 10:40AM

Discussion

Mechanism of liver injury




2 categories of blunt liver trauma:




Deceleration trauma fall from height


create fissure in the hepatic parenchyma, typically between
right posterior and right anterior sector, may involve major
vessels

Crush injury direct trauma to the abdomen over liver


area

Penetrating trauma may not associate with parenchymal


disruption, but life threatening hemorrhage if major
vessel is transected

Symptoms & Signs















Shock, hypotension
Abdominal distension
Anterior abdominal wall bruising
Abdominal pain
Peritoneal signs
Shoulder tip pain (subdiaphragmatic hematoma causing phrenic
nerve irritation)
Penetrating low thoracic wound
Posterior penetrating wound below scapula
Abdominal sonography: intraperitoneal fluid
Diagnostic peritoneal lavage (DPL): blood
CT: blood, collapsed cava, shock nephrogram, small hypodense
spleen (gold stander)

Image Grading

CT in Blunt Liver Trauma. Woong Yoon, MD ; RadioGraphics 2005; 25:87104

Treatment


Hemodynamically
stable:

Diagnosis and management of blunt


abdominal solid organ injury.
Thomas J. Schroeppel ; Current
Opinion in Critical Care 2007, 13:399
404






IVF challenge
Blood transfusion
Angiographic embolization
Monitor Hct and vital signs

Hemodynamically
unstable:

DPL: diagnostic peritoneal lavage


FAST: focused assessment by
sonography for trauma

Diagnosis and management of blunt


abdominal solid organ injury.
Thomas J. Schroeppel ; Current
Opinion in Critical Care 2007, 13:399
404

Operation:









Principles: control of bleeding, removal of


devitalized tissue, adequate drainage
Simple suture with or without hemostatic agents
Deep mattress suture
Packing
Debridement
Resection
Mesh hepatorrhaphy

Prognosis


Overall mortality rate: 8~10% ; morbidity rate:


18~30%
Nonoperative management:




Grade 1~3: success rate near 95%


Grade 4~5: success rate 75~80%
Complication rate 11%: most could be managed with
angioembolization for contrast extravasation, CT-guided
drainage for hepatic abscess and bilomas, laparoscopy for bile
peritonitis, and endoscopic retrograde
cholangiopancreatography (ERCP) for persistent bile leaks.

Operative management:



Operative mortality is 2043%


Complication: postoperative bleeding(10%), intraabdominal abscess(7.2%), biliary fistula (7~10%),
hemobilia(rare)

References




Sabiston: textbook of surgery. 17th ed.


Emergency imageing. R. Brooke Jeffery, 1st ed.
Hepatobiliary and pancreatic surgery. O. James
Garden, 2nd ed.
Diagnosis and management of blunt abdominal solid
organ injury. Thomas J. Schroeppel ; Current Opinion
in Critical Care 2007, 13:399404
CT in Blunt Liver Trauma. Woong Yoon, MD ;
RadioGraphics 2005; 25:87104
Advances and Changes in the Management of Liver
Injuries. SEONG K. LEE ; THE AMERICAN
SURGEON March 2007, 201-206