Hepatic trauma: CT findings and considerations based on our experience in emergency diagnostic imaging
Introduction
Abdominal blunt trauma represents the main cause of death in people of age less than 40 years [1]. The liver is frequently involved in this kind of event, with an incidence varying from 3 to 10%. Isolated hepatic lesions are rare and in 77–90% of cases, lesions of other organs and viscera are involved.
The Institution of Specialized Trauma Centers and the technical progress in imaging methodology developed over recent years allowed a reduction of mortality (death from hepatic trauma was 60% at the beginning of the 1940s but now accounts for some 15% for major lesions [2]).
Clinical findings in hepatic trauma are upper right abdominal quadrant pain, extending in some case to the right shoulder, hypotension and hemorragic shock, biliary peritonitis with diffuse pain and absence of intestinal paresis.
In the past, clinicians and surgeons based their evaluation on clinical findings because radiology provided little information in trauma, showing only skeletal lesions and free peritonal air. Patients in critical clinical condition were submitted to surgery; the introduction of diagnostic peritoneal lavage (LPD) represented an important diagnostic tool, with its sensibility in individuation of peritoneal hemorrhage [3], however, this methodology cannot help clinicians in determining the origin and extension of a traumatic lesion. False positive results were due to iatrogenic lesions caused by introduction of the catheter or blood from retroperitoneal collections [4]. LPD ameliorated the diagnostic approach to the traumatized patient but the percentage of negative laparotomies was of 6–25%, due to false positive or abdominal non-haemorrhagic lesions at surgery [5], [6].
Introduction of modern imaging techniques, such as sonography and computed tomography (CT), allow direct visualization of abdominal lesions, allowing their characterization and showing peritoneal fluid and active bleeding [7], [8], [9], [10].
Generally, patients in non-critical condition are submitted in the Emergency Department to sonographic examination for detection of fluid collections and, if possible, of parenchymal lesions. Sonographic findings of a traumatic lesion or of peritoneal fluid are an indication for CT examination [11], [12]. Patients in critical clinical condition go directly to CT examination of the abdomen and pelvis.
New diagnostic methodologies allow a reduction in negatives laparotomies and allow conservative treatment of numerous traumatic lesions; however, therapy depends on imaging findings and the clinical condition of the patient [13], [14].
Section snippets
Mechanism of trauma
Hepatic lesions are more frequent in abdominal blunt trauma; the mechanism involved is an acceleration followed by a sudden deceleration, as usually happens in car-crash events. The more involved site is the right lobe, posterior–superior segments particularly, because it is the more voluminous portion of the liver; posterior superior hepatic segments are proximal to fixed anatomical structures such as ribs and spine, that may have an important role in producing the lesion.
Coronal ligamentous
Computed tomography. Technical notes
CT is a non-invasive imaging method, easy to perform, and with high sensitivity (99%), specificity (96.8%) and accuracy (97.6%) in the diagnosis of traumatic hepatic lesions [7].
Introduction of state of the art volumetric CT has greatly reduced the examination time, always important in critically ill patients.
CT is useful for monitoring lesions in the case of conservative therapy and for detection of any eventual complications such ad seroma, biloma, abscess, necrosis, pseudoaneurysm [16]. CT
Classification and grading of hepatic traumatic lesions
Several classifications of hepatic lesions due to abdominal trauma have been proposed: The Moore classification [20] is based on laparotomy findings and the Mirvis classification considers CT findings [21]; site, dimension, superficial edge involvement, depth of parenchymal laceration or devascularization, and evidence of haemoperitoneum are important parameters considered.
The Mirvis classification [21] considers a grading of hepatic injury varying from capsular avulsion, superficial
CT findings of hepatic traumatic lesions
As reported in literature [20], [21], [22], radiological findings of traumatic lesion of the liver are: periportal tracking, contusion, subcapsular/central hematoma, complex laceration, fragmentation and avulsion of the hepatic pedicle.
Periportal tracking (Fig. 1) appears as a hypodense area, well described in literature: In 1989, Macrander et al. reported a retrospective series of 51 patients with hepatic injury [23] in whom this finding was found in 62% and in 9 cases was the unique CT sign
Portal or suprahepatic venous branches lacerations
Laceration of the main vascular bundles is a rare condition with consequent important intraparenchymal and peritoneal hemorrhage requiring immediate surgery.
Pseudoaneurysms
Arterial pseudoaneurysm (Fig. 7) development near a hepatic laceration is a frequently event in which the typical manifestation is haemorrhage [19]; it is caused by an intimal laceration of the vessel due to trauma. Usually, angiographic embolization is the interventional therapy required.
Artero-venous fistula
This is a rare event, frequently observed in
Conclusions
Of all diagnostic radiological techniques, CT certainly has had a large impact on the diagnosis and management of patients with lesions from blunt abdominal trauma [31].
It is important to establish prognostic criteria allowing decisions on conservative or surgical treatment; CT findings and peritoneal fluid evaluation may be used to do a first assessment of the severity of lesions, but haemodynamic parameters may help clinicians to prefer conservative treatment. In our experience, beneficial
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