A liver injury, also known as liver laceration, is some form of

trauma Trauma most often refers to: * Major trauma, in physical medicine, severe physical injury caused by an external source * Psychological trauma, a type of damage to the psyche that occurs as a result of a severely distressing event *Traumatic i ...

sustained to the

liver The liver is a major organ only found in vertebrates which performs many essential biological functions such as detoxification of the organism, and the synthesis of proteins and biochemicals necessary for digestion and growth. In humans, it ...

. This can occur through either a

blunt Blunt may refer to: * Blunt (surname), a surname (and list of people with the name) * Blunt (cigar), a term used in the cigar industry to designate blunt-tipped, usually factory-rolled cigars * Blunt (cannabis), a slang term used in cannabis cult ...

force such as a car accident, or a penetrating foreign object such as a

knife A knife ( : knives; from Old Norse 'knife, dirk') is a tool or weapon with a cutting edge or blade, usually attached to a handle or hilt. One of the earliest tools used by humanity, knives appeared at least 2.5 million years ago, as evidence ...

. Liver injuries constitute 5% of all traumas, making it the most common abdominal injury. Generally nonoperative management and observation is all that is required for a full recovery.

Cause

Given its anterior position in the abdominal cavity and its large size, the liver is prone to gun shot wounds and

stab wound A stab wound is a specific form of penetrating trauma to the skin that results from a knife or a similar pointed object. While stab wounds are typically known to be caused by knives, they can also occur from a variety of implements, including brok ...

s. Its firm location under the diaphragm also makes it especially prone to shearing forces. Common causes of this type of injury are blunt force mechanisms such as motor vehicle accidents, falls, and

sports injuries Sports injuries are injuries that occur during sport, athletic activities, or exercising. In the United States, there are approximately 30 million teenagers and children who participate in some form of organized sport. Of those, about three mi ...

. Typically these blunt forces dissipate through and around the structure of the liver and causes irreparable damage to the internal microarchitecture of the tissue. With increasing velocity of the impact, the internal damage of the liver tissue also exemplifies - even though the tissue itself is mechanically and micro-structurally isotropic. A large majority of people who sustain this injury also have another accompanying injury.

Diagnosis

Imaging, such as the use of

ultrasound Ultrasound is sound waves with frequencies higher than the upper audible limit of human hearing. Ultrasound is not different from "normal" (audible) sound in its physical properties, except that humans cannot hear it. This limit varies ...

or a computed tomography scan, is the generally preferred way of diagnosis as it is more accurate and is sensitive to bleeding, however; due to logistics this is not always possible. For a person who is hemodynamically unstable a

focused assessment with sonography for trauma Focused assessment with sonography in trauma (commonly abbreviated as FAST) is a rapid bedside ultrasound examination performed by surgeons, emergency physicians, and paramedics as a screening test for blood around the heart (pericardial effusio ...

(FAST) scan may take place which is used to find free floating fluid in the

right upper quadrant The human abdomen is divided into quadrants and regions by anatomists and physicians for the purposes of study, diagnosis, and treatment. The division into four quadrants allows the localisation of pain and tenderness, scars, lumps, and other ...

and left lower quadrant of the abdomen. The FAST scan however may not be indicated in those who are obese and those with subcutaneous emphysema. Its speed and sensitivity to injuries resulting in 400mL of free-floating fluid make it a valuable tool in the evaluation of unstable persons. Computed tomography is another diagnostic study which can be performed, but typically is only used in those who are hemodynamically stable. A physical examination may be used but is typically inaccurate in blunt trauma, unlike in penetrating trauma where the trajectory the projectile took can be followed digitally. A

diagnostic peritoneal lavage Diagnostic peritoneal lavage (DPL) or diagnostic peritoneal aspiration (DPA) is a surgical diagnostic procedure to determine if there is free floating fluid (most often blood) in the abdominal cavity. Indications This procedure is performed when i ...

(DPL) may also be utilized but has limited application as it is hard to determine the origin of the bleeding. A diagnostic peritoneal lavage is generally discouraged when FAST is available as it is invasive and non-specific.

Classification

Liver injuries are classified on a

Roman numeral Roman numerals are a numeral system that originated in ancient Rome and remained the usual way of writing numbers throughout Europe well into the Late Middle Ages. Numbers are written with combinations of letters from the Latin alphabet, ea ...

scale with I being the least severe, to VI being the most severe. Generally any injury ≥III requires surgery.

Management

The initial management of liver trauma generally follows the same procedures for all traumas with a focus on maintaining

airway The respiratory tract is the subdivision of the respiratory system involved with the process of respiration in mammals. The respiratory tract is lined with respiratory epithelium as respiratory mucosa. Air is breathed in through the nose to ...

, breathing, and circulation. A physical examination is a cornerstone of the assessment of which there are various

non-invasive A medical procedure is defined as ''non-invasive'' when no break in the skin is created and there is no contact with the mucosa, or skin break, or internal body cavity beyond a natural or artificial body orifice. For example, deep palpation and p ...

means of diagnostic tools that can be utilized. An invasive

can also be used to diagnose and classify the extent of the damage. A large majority of liver injuries are minor and require only observation. Generally if there is estimated to be less than 300mL of free floating fluid, no injury to surrounding organs, and no need for blood transfusion, there is a low risk of complication from nonoperative management. In special cases where there is a higher risk with surgery, such as in the elderly, nonoperative management would include the

infusion Infusion is the process of extracting chemical compounds or flavors from plant material in a solvent such as water, oil or alcohol, by allowing the material to remain suspended in the solvent over time (a process often called steeping). An in ...

packed red blood cell Packed red blood cells, also known as packed cells, are red blood cells that have been separated for blood transfusion. The packed cells are typically used in anemia that is either causing symptoms or when the hemoglobin is less than usually 70 ...

s in an

intensive care unit 220px, Intensive care unit An intensive care unit (ICU), also known as an intensive therapy unit or intensive treatment unit (ITU) or critical care unit (CCU), is a special department of a hospital or health care facility that provides intensi ...

. Typically hepatic injuries resulting from stab wounds cause little damage unless a vital part of the liver is injured, such as the

hepatic portal vein The portal vein or hepatic portal vein (HPV) is a blood vessel that carries blood from the gastrointestinal tract, gallbladder, pancreas and spleen to the liver. This blood contains nutrients and toxins extracted from digested contents. Approx ...

; with

gunshot wound A gunshot wound (GSW) is a penetrating injury caused by a projectile (e.g. a bullet) from a gun (typically firearm or air gun). Damages may include bleeding, bone fractures, organ damage, wound infection, loss of the ability to move part ...

s, the damage is worse.

Surgery

In severe liver injuries (class ≥III), or those with hemodynamic instability, surgery is generally necessary. Surgical techniques such as

perihepatic packing Perihepatic packing is a surgical procedure used in connection with trauma surgery to the liver. In this procedure the liver is packed to stop non arterial bleeding, most often caused by liver injury. During this surgery laparotomy pads are plac ...

or the use of the

Pringle manoeuvre The Pringle manoeuvre is a surgical technique used in some abdominal operations and in liver trauma. The hepatoduodenal ligament is clamped either with a surgical tool called a haemostat, an umbilical tape or by hand. This limits blood inflow thr ...

can be used to control

hemorrhage Bleeding, hemorrhage, haemorrhage or blood loss, is blood escaping from the circulatory system from damaged blood vessels. Bleeding can occur internally, or externally either through a natural opening such as the mouth, nose, ear, urethra, v ...

. Temporary control of the hemorrhage can be accomplished through direct manual pressure to the wound site. In these severe cases it is important to prevent the progression of the trauma triad of death, which often requires the utilization of damage control surgery. New devices are being developed in order to control the bleeding using negative pressure. The common cause of death while operating is

exsanguination Exsanguination is death caused by loss of blood. Depending upon the health of the individual, people usually die from losing half to two-thirds of their blood; a loss of roughly one-third of the blood volume is considered very serious. Even a sin ...

caused by profuse loss of blood volume. Rarely, surgery entails the use of liver resection, which removes the source of the bleeding and

necrotic Necrosis () is a form of cell injury which results in the premature death of cells in living tissue by autolysis. Necrosis is caused by factors external to the cell or tissue, such as infection, or trauma which result in the unregulated dige ...

tissue. The drastic nature of this procedure means it can only be used in hemodynamically stable patients. Another rare procedure would be liver transplantation which is typically impractical due to the

logistics Logistics is generally the detailed organization and implementation of a complex operation. In a general business sense, logistics manages the flow of goods between the point of origin and the point of consumption to meet the requirements of ...

of finding a proper

organ donor Organ donation is the process when a person allows an organ of their own to be removed and transplanted to another person, legally, either by consent while the donor is alive or dead with the assent of the next of kin. Donation may be for res ...

in a timely fashion.

History

In the 1880s a severe liver injury would in most cases prove fatal in the first 24 hours after sustaining the injury. Before the 1980s nonoperative management was seldom used in favor of the methods of management suggested by

James Hogarth Pringle James Hogarth Pringle (born 26 January 1863 in Parramatta, Australia – died 24 April 1941 in Killearn, Scotland) was an Australian-born British surgeon in Glasgow, who made a number of important contributions to surgical practice. He is most f ...

. During World War II the use of early

laparotomy A laparotomy is a surgical procedure involving a surgical incision through the abdominal wall to gain access into the abdominal cavity. It is also known as a celiotomy. Origins and history The first successful laparotomy was performed without ane ...

was popularized and in conjunction with the use of transfusions, advanced anesthetics, and other new surgical techniques led to decreased mortality.Moore 2012, p. 539

Cause

Diagnosis

Classification

Management

Surgery

History

References

Bibliography

External links