Hepatic trauma: CT findings and considerations based on our experience in emergency diagnostic imaging

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Abstract

Abdominal blunt trauma represents the main cause of death in people of age less than 40 years; the liver injury occurs frequently, 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.

Right hepatic lobe is a frequent site of injury, because it is the more voluminous portion of liver parenchyma; posterior superior hepatic segments are proximal to fixed anatomical structures such as ribs and spine that may have an important role in determining of the lesion. The coronal ligaments’ insertion in this parenchymal region augments the effect of acceleration–deceleration mechanism. Associated lesions usually are homolateral costal fractures, laceration or contusion of the inferior right pulmonary lobe, haemothorax, pneumothorax, renal and/or adrenal lesions. Traumatic lesions of left hepatic lobe are rare and usually associated with direct impact on the superior abdomen, such as in car-crash when the wheel causes a compressive effect on thorax and abdomen. Associated lesions to left hepatic lobe injuries correlated to this mechanism are: sternal fractures, pancreatic, myocardial, gastrointestinal tract injuries. Lesions of the caudal lobe are extremely rare, usually not isolated and noted with other large parenchymal lesions.

The Institution of Specialized Trauma Centers and the technical progress in imaging methodology developed in the last years a great reduction of mortality.

New diagnostic methodologies allow a reduction of negatives laparotomies and allow the possibility of conservative treatment of numerous traumatic lesions; however, therapy depends from imaging findings and clinical conditions of the patient. Computed tomography (CT) certainly presents a large impact on diagnosis and management of patients with lesions from blunt abdominal traumas. It is important to establish a prognostic criteria allowing decisions for conservative or surgical treatment; CT findings and peritoneal fluid evaluation may be used to make a first differentiation of severity of lesions, but haemodynamic parameters may help the clinician to prefer a conservative treatment.

In emergency based hospitals and also in our experience, positive benefits spring from diagnostic accuracy and consequent correct therapeutic management.

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

References (33)

  • D.G. Jacobs et al.

    Abdominal CT scanning for trauma: how low can we go?

    Injury

    (2000)
  • J. Yokota et al.

    Clinical significance of periportal tracking on computed tomographic scan in patients with blunt liver trauma

    Am. J. Surg.

    (1994)
  • P.J. Haney et al.

    Liver injury and complications in the post-operative trauma patients: CT evaluation

    AJR

    (1982)
  • Anderson CB, Ballinger WF, Abdominal injuries. In: Zuidema GD, et al., editor. The management of trauma. 4th ed....
  • M.G. Catre

    Diagnostic peritoneal lavage versus abdominal computed tomography in blunt abdominal trauma: a review of prospective studies

    Can. J. Surg.

    (1995)
  • T.S. Mele et al.

    Evaluation of a diagnostic protocol using screening diagnostic peritoneal lavage with selective use of abdominal computed tomography in blunt abdominal trauma

    J. Trauma

    (1999)
  • R.P. Gonzales et al.

    Complementary roles of diagnostic peritoneal lavage and computed tomography in the evaluation of blunt abdominal trauma

    J. Trauma

    (2001)
  • T.C. Fabian et al.

    A prospective styudy of 91 patients undergoing both computed tomography and peritoneal lavage following blunt abdominal trauma

    J. Trauma

    (1986)
  • J. Kinnunen et al.

    Emergency CT in blunt abdominal trauma of multiple injury patients

    Acta. Radiologica.

    (1994)
  • M.P. Federle et al.

    Hemoperitoneum studied by computed tomography

    Radiology

    (1983)
  • C.J. Sivit

    Detection of active intrabdominal hemorrhage after blunt trauma: value of delayed CT scanning

    Pediatr. Radiol.

    (2000)
  • S.S. Lingawi et al.

    Focused abdominal US in patients with trauma

    Radiology

    (2000)
  • M. Brown et al.

    Blunt abdominal trauma: screening US in 2,693 patients

    Radiology

    (2001)
  • J.P. McGahan et al.

    From the RSNA refresher courses: focused abdominal US for trauma

    Radiographics

    (2001)
  • D.H. Livingstone et al.

    Free fluid on abdominal computed tomography without solid organ injury after blunt abdominal injuries does not mandate celiotomy

    Am. J. Surg.

    (2001)
  • K. Shanmugana et al.

    CT evaluation of the liver with acute blunt trauma

    Crit. Rev. Diagn. Imaging

    (1995)

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