| disease | Liver Injury |
| alias | Injury of Liver |
The liver is the largest solid organ in the abdominal cavity and performs vital physiological functions in the human body. Liver cells have poor tolerance to hypoxia, hence the hepatic artery and portal vein provide abundant blood supply, accompanied by bile ducts and blood vessels that transport bile. It is located deep in the right upper abdomen, protected by the lower chest wall and diaphragm. However, due to its large size and fragile texture, the liver is prone to injury when subjected to trauma, leading to intra-abdominal hemorrhage or bile leakage, which can cause hemorrhagic shock and/or biliary peritonitis. The consequences are severe, necessitating prompt diagnosis and proper management.
bubble_chart Pathological Changes
After the liver is subjected to blunt force, different types of liver lacerations can occur depending on the severity of the force. Mild cases involve superficial lacerations with minimal bleeding, some of which may stop on their own; severe cases involve deeper lacerations, some of which may be irregularly stellate or even severely shattered, losing vitality or detaching into the abdominal cavity. This {|###|}injury{|###|} primarily manifests as intra-abdominal bleeding and hemorrhagic shock. Blood has a certain irritant effect on the abdominal {|###|}membrane{|###|}, leading to grade I abdominal {|###|}membrane{|###|} irritation signs. If combined with bile duct rupture, {|###|}gall fel{|###|} external {|###|}fistula disease{|###|} may result in more severe signs of {|###|}gall fel{|###|} peritonitis. Injury to the main trunk of the hepatic vein, the retrohepatic segment of the inferior vena cava, or the branches of the portal vein can cause continuous massive bleeding, rapidly leading to shock or even sudden death. Devitalized or scattered liver tissue in the abdominal cavity will necrotize and decompose, and together with accumulated blood and {|###|}gall fel{|###|}, it can lead to secondary bacterial infections, forming intra-abdominal abscesses. Subcapsular liver lacerations, due to the intact capsule, result in bleeding from the ruptured liver parenchyma accumulating under the capsule to form a hematoma. Mild {|###|}traumatic hemorrhage{|###|} involves little bleeding, forming small hematomas that may resolve on their own; severe injuries involve significant bleeding, which can widely separate the liver capsule to form large hematomas. The pressure from the hematoma can also cause necrosis in the surrounding hepatocytes. Hematomas may also become secondarily infected, forming abscesses. High-tension hematomas can rupture the capsule, converting into true lacerations. Central liver lacerations primarily involve deep parenchymal rupture while the liver capsule and superficial parenchyma remain intact. Such lacerations can form large hematomas deep within the liver, increasing liver volume and tension, with the surrounding tissue compressed and necrotized. These hematomas may rupture into the abdominal cavity, causing internal bleeding and peritonitis, or into the bile ducts, presenting as biliary hemorrhage, or may become secondarily infected, forming liver abscesses.
The severity of open or penetrating {|###|}injury{|###|} depends on the location of the liver injury and the penetrating velocity of the object. Bullets and shrapnel can transfer energy to the surrounding tissue along the trajectory, causing damage. Injury to major blood vessels in the hepatic hilum may not severely damage the liver parenchyma, but due to continuous massive bleeding, the mortality rate remains high. Besides the type and severity of the {|###|}injury{|###|}, concomitant multi-organ {|###|}injury{|###|} is a significant factor affecting the mortality rate of liver trauma. The more organs injured, the more severe the condition, the more difficult the treatment, and the higher the mortality rate.bubble_chart Clinical Manifestations
The clinical manifestations of liver injury mainly include intra-abdominal hemorrhage and peritoneal irritation caused by blood and bile, varying according to the type and severity of the injury.
(1) True liver laceration: Minor traumatic hemorrhage is limited and may stop spontaneously, with mild abdominal signs. Severe injury leads to massive hemorrhage and shock. The patient presents with pallor, cold extremities, cold sweats, rapid and thready pulse, followed by a drop in blood pressure. If combined with bile duct rupture, bile and blood irritate the peritoneum, causing abdominal pain, muscle guarding, tenderness, and rebound tenderness. Sometimes, bile irritation of the diaphragm may result in hiccups and referred shoulder pain.
(2) Subcapsular liver laceration: Most cases involve subcapsular hematoma. With mild injury, clinical manifestations are atypical, presenting only as liver area or right upper abdominal distension and dull pain, right upper abdominal tenderness, and liver area percussion pain. Occasionally, a tender liver may be palpated. There is no hemorrhagic shock or obvious peritoneal irritation. If secondary infection occurs, an abscess may form. Due to continued bleeding, the subcapsular hematoma gradually enlarges, increasing in tension, and may rupture after several hours or days, leading to a series of symptoms and signs of true liver laceration.
Open injuries, depending on the location of the wound, the depth and direction of the wound tract, diagnosing liver injury is usually not difficult. For closed true liver lacerations with obvious intraperitoneal bleeding and peritoneal irritation signs, the diagnosis is also straightforward. However, diagnosing liver lacerations may be challenging in cases of subcapsular liver lacerations, subcapsular hematomas, and central-type lacerations when symptoms and signs are not obvious. In such cases, a comprehensive analysis combining the injury condition and clinical manifestations is necessary, along with close monitoring of changes in vital signs and abdominal signs. The following diagnostic methods may be helpful:
(1) Diagnostic peritoneal puncture: This method is highly valuable for diagnosing intraperitoneal organ ruptures, especially for parenchymal organ lacerations. Generally, the aspiration of non-coagulating blood suggests visceral injury. However, false-negative results may occur with minimal bleeding, so a single negative puncture does not rule out visceral injury. If necessary, multiple punctures at different sites and times or diagnostic peritoneal lavage may be performed to aid diagnosis.
(2) Timed measurement of red blood cells, hemoglobin, and hematocrit: Observing dynamic changes in these parameters can indicate internal bleeding if progressive anemia is present.
(4) X-ray examination: In cases of subcapsular liver hematomas or intrahepatic hematomas, X-ray films or fluoroscopy may reveal an enlarged liver shadow and elevated diaphragm. If free gas under the diaphragm is also detected, it suggests combined hollow organ injury.
(5) Liver radionuclide scanning: For unclear closed injuries where subcapsular or intrahepatic hematomas are suspected, and the patient's condition is stable, liver radionuclide scanning may be performed. Hematomas appear as radioactive defect areas in the liver.
(6) Selective hepatic arteriography: For diagnostically challenging closed injuries, such as suspected intrahepatic hematomas in non-emergent cases, this method may be used. It can reveal diagnostic signs such as hepatic artery branch aneurysms or contrast extravasation. However, as an invasive and complex procedure, it should only be performed under specific conditions and not as a routine examination.
bubble_chart Treatment Measures
After the diagnosis of liver laceration is confirmed, early surgical treatment should be pursued. Most patients exhibit internal bleeding and hemorrhagic shock, and some may also have other organ injuries. Preoperative anti-shock management is crucial, as it can enhance the patient's tolerance to anesthesia and surgery. First, a reliable and effective blood transfusion route must be established. Selecting a branch of the superior vena cava for transfusion is preferable, as some injuries may involve laceration of the inferior vena cava, making transfusions from the lower limbs potentially obstructed or leading to fistula disease, thereby failing to achieve the goal of replenishing blood volume. Some severe liver injuries are accompanied by major vascular ruptures with massive bleeding, and even aggressive, rapid, and large-volume blood transfusions may fail to stabilize blood pressure. In such cases, a decisive laparotomy should be performed while continuing anti-shock treatment to control active bleeding. Further surgical procedures can be carried out once the shock has improved.
The principles of surgical management for liver injuries include thorough hemostasis, removal of devitalized liver tissue, and placement of abdominal drainage to prevent secondary infection. Hemostasis is the key to managing liver injuries, and the ability to effectively control bleeding directly impacts the mortality rate. Devitalized liver tissue will undergo necrosis and disintegration, and accumulated blood and bile will eventually lead to secondary infection and the formation of intra-abdominal abscesses.
(1) Management of True Liver Lacerations There are many methods for hemostasis. In cases of significant bleeding, the hepatic pedicle can be clamped first, and then one of the following methods can be selected based on the specific injury.
1. Simple Suture Method Suitable for regular linear liver lacerations. Generally, 4-0 silk or 1-0 catgut sutures with a slender round needle are used to perform "8"-shaped or mattress sutures through the wound base. The ligation should be gentle to prevent the suture from cutting through the liver tissue. If oozing persists, hot saline gauze can be applied for compression hemostasis.
2. Debridement For large and deep liver lacerations, devitalized liver tissue should first be removed. The severed ends of blood vessels or bile ducts on the wound surface should be ligated individually. Active bleeding points retracted into the liver tissue can be controlled with "8"-shaped sutures. After hemostasis, if deep dead spaces remain when the wound edges are approximated, simple closure should be avoided. The wound can be left open and covered with a pedicled omentum, or the omentum can be embedded to eliminate the dead space before closure, followed by drainage placement.
3. Hepatic Artery Ligation If the above methods fail to achieve hemostasis, ligation of the proper hepatic artery or its branches on the injured side may be considered. Bleeding originating from the hepatic artery can be effectively controlled with this method.
4. Hepatectomy Severe and uncontrollable bleeding from fragmented liver injuries may require hepatectomy to remove devitalized liver tissue for complete hemostasis. Anatomical resection is usually unnecessary. Hemorrhage can be controlled using a tourniquet, liver clamp, or manual pinching. After excising the devitalized tissue, blood vessels and bile ducts on the cut surface should be ligated separately. The liver surface can be covered with a pedicled omentum or adjacent ligaments, followed by drainage placement.
5. Packing Hemostasis When suturing, hepatic artery ligation, or hot saline gauze compression fail to control extensive oozing or bleeding, and the patient's condition is critical, large pieces of gelatin sponge, hemostatic powder, or absorbable gauze can be packed into the wound for compression hemostasis. If bleeding persists, additional large gauze strips or pads can be packed for pressure hemostasis. Prophylactic antibiotics and hemostatic agents should be administered postoperatively. The gauze pads or strips can be removed in stages in the operating room after 3–5 days once the patient stabilizes. Packing is an emergency measure and should only be used when all other hemostatic methods fail, as it carries a high risk of secondary infection, bleeding, or biliary fistula.
(2) Management of Subcapsular Hematomas Most cases result from continued bleeding from lacerated liver tissue, leading to increasing tension in the liver capsule and eventual expansion or rupture of the capsule. During surgery, the capsule should be incised to evacuate the hematoma, ligate or suture bleeding points, and close the laceration, followed by drainage placement.
(3) Management of Central Liver Laceration In this type of injury, the liver capsule and superficial parenchyma remain intact, making diagnosis difficult. During surgical exploration, if the liver is found to be enlarged with increased capsular tension, central liver rupture should be suspected. Diagnosis can generally be aided by liver puncture and aspiration, intraoperative puncture angiography, or selective hepatic artery angiography. If a large dead space or hematoma is confirmed, debridement, hemostasis, and drainage should be performed. For more severe lacerations where conventional ligation or suturing fails to achieve hemostasis, consideration should be given to omentum packing followed by suturing or partial hepatectomy.
(4) Management of penetrating liver injuries If the injury is not linear, a catheter can be inserted through the entry or exit wound to aspirate the tract or flush it with saline to remove blood clots, foreign bodies, and fragmented liver tissue. If bleeding has stopped, the wound generally does not require suturing, and drainage can be placed near the entry and exit sites. If there is a large dead space or active bleeding within the tract, debridement, hemostasis, and drainage should be performed via incision.
(5) Management of injuries to the hepatic vena cava segment or major hepatic veins These injuries typically involve significant bleeding and carry the risk of air embolism, but they are difficult to diagnose, and direct suturing for hemostasis is extremely challenging. If substantial bleeding persists after the aforementioned measures, the possibility of an injury to the inferior vena cava or hepatic veins should be considered. The surgical procedure can be performed as follows: Pack the lacerated area with gauze pads to control bleeding, extend the incision to the right 7th and 8th intercostal spaces, lift the liver to expose the second hepatic hilum, block blood flow through the hepatoduodenal ligament, and control blood flow above and below the vena cava laceration. Under direct vision, repair the ruptured major hepatic vein or inferior vena cava, then restore the blocked blood flow.
The most common complications are infections, followed by biliary fistula, secondary hemorrhage, and acute hepatic and renal failure.
(1) Infectious complications include liver abscess, subphrenic abscess, and wound infection. Thorough removal of devitalized liver tissue and contaminants, proper hemostasis, and placement of reliable and effective drainage are effective measures to prevent infections. Once an abscess forms, timely drainage is necessary.
(2) Biliary fistula at the liver wound can lead to biliary peritonitis or localized intra-abdominal abscess, which is also a serious complication. The method to prevent biliary fistula is to carefully ligate or suture the severed bile ducts of various sizes during surgery and place drainage tubes. After the occurrence of biliary fistula, placing a "T" tube in the common bile duct for drainage can reduce biliary tract pressure and promote healing.
(3) Secondary hemorrhage is often caused by improper wound management, leaving dead spaces or necrotic tissue, leading to secondary infection, which results in vascular rupture or ligation slippage and rebleeding. In cases of significant hemorrhage, reoperation for hemostasis and improved drainage are required.
(4) Acute hepatic, renal, and pulmonary dysfunction is an extremely severe and difficult-to-manage complication with a poor prognosis. It often results from severe complex liver injury, prolonged shock after massive blood loss, excessive duration of hepatic blood flow occlusion, or severe intra-abdominal infection. Therefore, timely correction of shock, attention to the duration of hepatic blood flow occlusion, proper management of liver wounds, placement of effective abdominal drainage, and infection prevention are crucial measures to prevent such multi-organ failure and currently represent the best treatment for multi-organ failure.
