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 Table of Contents  
Year : 2021  |  Volume : 2  |  Issue : 1  |  Page : 34-36

Concealed hepatic injuries: Where to look and how to manage?

1 Division of Interventional Radiology, All India Institute of Medical Sciences, Rishikesh, Uttarakhand, India
2 Department of Trauma Surgery, All India Institute of Medical Sciences, Rishikesh, Uttarakhand, India

Date of Submission23-May-2020
Date of Decision11-Jun-2020
Date of Acceptance23-Jun-2020
Date of Web Publication25-Apr-2021

Correspondence Address:
Dr. Mohit Tayal
Division of Interventional Radiology, All India Institute of Medical Sciences, Rishikesh, Uttarakhand
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Source of Support: None, Conflict of Interest: None

DOI: 10.4103/JME.JME_46_20

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How to cite this article:
Chauhan U, Tayal M, Ratan A, Sharma P. Concealed hepatic injuries: Where to look and how to manage?. J Med Evid 2021;2:34-6

How to cite this URL:
Chauhan U, Tayal M, Ratan A, Sharma P. Concealed hepatic injuries: Where to look and how to manage?. J Med Evid [serial online] 2021 [cited 2022 Aug 12];2:34-6. Available from: http://www.journaljme.org/text.asp?2021/2/1/34/314631

  Introduction Top
Liver is a commonly injured solid organ after blunt trauma and frequently associated with other concomitant injuries. Nearly 5% of the total admissions in hospitals are related to liver injuries. Outcome in terms of morbidity and mortality depends on the degree of hepatic injury. Majority of the injuries are mild in nature with low mortality rates. However, Grade IV injuries are often fatal.[1] Patients often require prompt assessment and triage. Injuries to solid abdominal organs were common on abdominal computed tomography (CT) in a recent study that comprised subject size of 1000 patients following abdominal trauma.[2] Another study on about 224 cases revealed that regardless of haemodynamic stability, CT identified significant cases of splenic, hepatic and renal injuries.[3] With the development of technique and availability of advanced hardware enabling selective catheterisation with micro-catheters, embolisation therapies are increasingly becoming popular.
  Case Report Top
A 34-year-old patient presented to the trauma surgery department with a history of blunt trauma to the abdomen, following road traffic accident within 4 h of injury. At preliminary workup, his systolic blood pressure was 100 mmHg, pulse rate was 120/min and Glasgow coma scale score was 11. Radiographs of the chest and pelvis revealed no haemothorax, no pneumothorax and no fractures. There was no free fluid noted in the abdomen on extended focused assessment with sonography in trauma (eFAST). Triple-phase contrast-enhanced CT (CECT) of the chest and abdomen was unremarkable. Feature of chronic liver disease corresponding to Child Pugh Class B was present on the cross-sectional imaging [Figure 1]a and [Figure 1]b. A consensus decision was made to keep the patient under observation. Post-admission after 7–8 h, the patient developed tachycardia (approximately 160 beats per minute), and systolic blood pressure plunged to 64 mmHg. A fall in haemoglobin from 12 to 9 g/dl was noted in repeat haemogram. Endotracheal intubation was done, and the patient was put on ventilator. Fluid resuscitation along with inotropic support was needed to maintain blood pressure. There was correction in systolic blood pressure which reached to 90 mmHg, but tachycardia persisted and the patient was heading towards haemorrhagic shock. Eight units of whole blood was also transfused. In view of requirement of on-going blood transfusion and inotropic support, a repeat triple-phase CECT of the abdomen was performed to rule out occult arterial haemorrhage. The findings were again inconclusive, but it did reveal inconspicuous small area of linear hypodensity in the segment VIII of the right lobe of liver. There was an associated anterior peri-hepatic expanding haematoma that was masked by the streak artefacts, emanating from upper limb bones, placed by the side of patient [Figure 1]c and [Figure 1]d. It was decided to perform digital subtraction angiography (DSA) ahead of laparotomy, in view of co-existing chronic liver disease.
Figure 1: (a and b) Axial contrast-enhanced computed tomography scan at the time of presentation to hospital revealing insignificant findings, however features of chronic liver disease are seen. Interval scan after 12 h showing linear hypodense areas masked by streak artefacts (c, curved arrow). Anterior expanding peri-hepatic haematoma is also noted (d, straight arrow)

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The patient was taken in DSA suite. An ipsilateral approach through the right common femoral artery was made, and a 6-French vascular sheath (Boston Scientific, Boston, MA, USA) was placed under ultrasound guidance. A 5-French Cobra catheter (Cook Medical, Bloomington, IN, USA) was used to engage the celiac trunk. Angiogram at 2 frames per second was performed using iobitridol (350 mg/ml, Xenetix, Guerbet, France) which revealed active extravasation near to the surface from sub-segmental (segment VIII) branch of the right hepatic artery. Following the identification and affirmation, a 2.7-French micro-catheter (Progreat Terumo, Somerset, NJ, USA) was coaxially advanced avoiding injury or arterial spasm. The tip of catheter was placed as distally as possible under fluoroscopic guidance. Gel foam (Upjohn, Kalamazoo, MI, USA) was used as an embolising agent. Complete cessation of arterial bleeding was noted on arteriogram obtained post-embolisation [Figure 2]. Post-embolisation, the haemodynamic stability was achieved, and there was no requirement of further transfusion. The patient was discharged on day 7 of hospitalisation. Regular follow-ups were done at 15 days, 2 months and 4 months, and no complications were noted.
Figure 2: (a) Digital subtraction angiography revealing active extravasation (straight arrow) of the contrast material from sub-segmental (segment VIII) branch of the right hepatic artery. (b) Cessation of extravasation in post-embolisation selective angiography

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  Discussion Top
The recent time has witnessed increasing preference of trauma care teams towards non-operative treatment lines in the management of abdominal arterial injuries. The advent and evolution of cross-sectional imaging have paved a way for a more efficient treatment planning. Available literature has reiterated successful role of endovascular therapies in the primary management of hepatic injuries.[4],[5] Despite compelling evidence, the role of angiographic embolisation has been limited to either post-operative haemodynamically unstable patients or patients with Grade III or higher liver injuries.[6],[7],[8] It is not infrequent to miss subtle injuries to liver capsule and haemorrhages due to peripheral sub-segmental vessels during the first CT scan. Secondary signs such as delayed sub-capsular haematomas, flat inferior vena cava (due to intravascular volume loss) and peri-vascular hypodensities as a result of rapid fluid correction causing lymphatic overflow within lymphatic channels inside liver are known signs to indirectly indicate possible hepatic injuries on cross-sectional imaging.[9] In the case presented here, hepatic artery embolisation was considered in view of continued haemorrhage following negative eFAST and CECT, and the patient was not a candidate for open surgical procedure due to co-existing chronic liver disease. The primary use of hepatic artery embolisation in the setting of blunt liver trauma is described for patients who do not fit criteria for laparotomy, for control of delayed hepatic haemorrhage and for the prevention of haemorrhage from pseudoaneurysms and arteriovenous fistulas.[10],[11] Involvement of small- and medium-sized vessels has been frequently reported in cases of liver injuries, and back door revascularisation after proximal embolisation is not uncommon. Thus, super-selective embolisation with coil sandwich technique using micro-coils is described as appropriate management. In the present case, the extravasation was quite distal near to the surface, and coil sandwich technique was not possible. In such circumstances, particle or gelfoam embolisation is recommended to achieve distal control. The dual supply of liver from the arterial and portal system warrants extensive embolisation in traumatic liver injuries. Hepatic necrosis, gallbladder infarction and abscess formations are infrequently reported complications of the procedure.[10],[12],[13] Fortunately, in the present case, using super-selective gelfoam embolisation, no post-procedure complications were noted at 15 days, 2 months and 4 months of follow-up. In appropriate clinical settings, the demonstration of active contrast extravasations during the first CECT scan is considered a significant predictor of impending haemodynamic instability. Liver lacerations with or without involvement of bile ducts, intra-parenchymal, sub-hepatic and peri-hepatic haematomas and venous injuries are other commonly reported injuries. Lymphatic injury is suggested by peri-portal hypodensity on CECT.[9] In the present case, imaging findings were inconspicuous and only positive finding was expanding small anterior peri-hepatic haematoma on the interval CT scan. The authors stress upon the careful and meticulous review of imaging in trauma patients with emphasis upon subtle secondary signs and interval imaging. Declaration of patient consent The authors certify that they have obtained all appropriate patient consent forms. In the form, the patient has given his consent for his images and other clinical information to be reported in the journal. The patient understands that his name and initials will not be published and due efforts will be made to conceal identity, but anonymity cannot be guaranteed. Financial support and sponsorship Nil. Conflicts of interest There are no conflicts of interest.

  References Top

Badger SA, Barclay R, Campbell P, Mole DJ, Diamond T. Management of liver trauma. World J Surg 2009;33:2522-37.  Back to cited text no. 1
Deunk J, Brink M, Dekker HM, Kool DR, Blickman JG, van Vugt AB, et al. Predictors for the selection of patients for abdominal CT after blunt trauma: A proposal for a diagnostic algorithm. Ann Surg 2010;251:512-20.  Back to cited text no. 2
Fang JF, Wong YC, Lin BC, Hsu YP, Chen MF. Usefulness of multidetector computed tomography for the initial assessment of blunt abdominal trauma patients. World J Surg 2006;30:176-82.  Back to cited text no. 3
Carrillo EH, Platz A, Miller FB, Richardson JD, Polk HC Jr. Non-operative management of blunt hepatic trauma. Br J Surg 1998;85:461-8.  Back to cited text no. 4
Raza M, Abbas Y, Devi V, Prasad KV, Rizk KN, Nair PP. Non operative management of abdominal trauma-A 10 years review. World J Emerg Surg 2013;8:14.  Back to cited text no. 5
Stassen NA, Bhullar I, Cheng JD, Crandall M, Friese R, Guillamondegui O, et al. Nonoperative management of blunt hepatic injury: An Eastern Association for the Surgery of Trauma practice management guideline. J Trauma Acute Care Surg 2012;73:S288-93.  Back to cited text no. 6
Clemente N, di Saverio S, Giorgini E, Biscardi A, Villani S, Senatore G, et al. Management and outcome of 308 cases of liver trauma in Bologna Trauma Center in 10 years. Ann Ital Chir 2011;82:351-9.  Back to cited text no. 7
Virdis F, Reccia I, di Saverio S, Tugnoli G, Kwan SH, Kumar J, et al. Clinical outcomes of primary arterial embolization in severe hepatic trauma: A systematic review. Diagn Interv Imaging 2019;100:65-75.  Back to cited text no. 8
Yoon W, Jeong YY, Kim JK, Seo JJ, Lim HS, Shin SS, et al. CT in blunt liver trauma. Radiographics 2005;25:87-104.  Back to cited text no. 9
Monnin V, Sengel C, Thony F, Bricault I, Voirin D, Letoublon C, et al. Place of arterial embolization in severe blunt hepatic trauma: A multidisciplinary approach. Cardiovasc Intervent Radiol 2008;31:875-82.  Back to cited text no. 10
Hagiwara A, Yukioka T, Ohta S, Tokunaga T, Ohta S, Matsuda H, et al. Nonsurgical management of patients with blunt hepatic injury: efficacy of transcatheter arterial embolization. AJR Am J Roentgenol 1997;169:1151-6.  Back to cited text no. 11
Mohr AM, Lavery RF, Barone A, Bahramipour P, Magnotti LJ, Osband AJ, et al. Angiographic embolization for liver injuries: Low mortality, high morbidity. J Trauma 2003;55:1077-81.  Back to cited text no. 12
Dabbs DN, Stein DM, Scalea TM. Major hepatic necrosis: A common complication after angioembolization for treatment of high-grade liver injuries. J Trauma 2009;66:621-7.  Back to cited text no. 13


  [Figure 1], [Figure 2]


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