Blunt Trauma Abdomen (BTA) – Liver Injury

Anatomy & Why Liver is Commonly Injured

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The liver is the most commonly injured solid organ in blunt abdominal trauma because:

  • Large size (right upper quadrant dominance)
  • Fragile parenchyma
  • Rich dual blood supply:
    • Portal vein (75%)
    • Hepatic artery (25%)
  • Fixed position (ligaments → shear injury)

 Mechanism of Injury

1. Blunt Mechanisms

  • Road traffic accidents (most common)
  • Falls from height
  • Assault

2. Pathophysiology

  • Compression injury → liver crushed against ribs/spine
  • Deceleration injury → shearing at ligament attachments
  • Burst injury → ↑ intrahepatic pressure

 Types of Liver Injury

  • Capsular tear
  • Parenchymal laceration
  • Contusion/hematoma
  • Subcapsular hematoma
  • Vascular injury (hepatic veins/IVC)
  • Biliary injury (leak)

 AAST Liver Injury Grading 

Grade

Injury Type

I

Subcapsular hematoma <10%, laceration <1 cm

II

Hematoma 10–50%, laceration 1–3 cm

III

Hematoma >50% or laceration >3 cm

IV

Parenchymal disruption 25–75% of lobe

V

>75% disruption or major vascular injury

VI

Hepatic avulsion (rare, fatal)

Grade ≠ management decision alone → Hemodynamic status is  main


Clinical Features

Symptoms

  • Right upper quadrant pain
  • Referred shoulder pain (diaphragmatic irritation)

Signs

  • Tachycardia, hypotension → hemorrhagic shock
  • RUQ tenderness
  • Abdominal distension
  • Guarding/rigidity (if rupture)

 Diagnosis 

1. Primary Survey (ATLS)

  • ABCDE approach
  • Identify shock early

2. FAST (Focused Assessment with Sonography for Trauma)


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  • Detects free intraperitoneal fluid
  • Morrison’s pouch (hepatorenal recess) → most sensitive area
  • Limitations:
    • Cannot grade liver injury
    • Misses contained hematomas

3. CECT Abdomen

Findings:

  • Lacerations
  • Hematomas
  • Active contrast extravasation (“blush”) → ongoing bleeding
  • Vascular injuries
  • Bile leak

4. Labs

  • Hb (serial monitoring)
  • LFTs (AST/ALT ↑ suggest injury)
  • Coagulation profile
  • Lactate (shock marker)

Management 

Hemodynamic stability determines management, NOT CT grade alone


1. Non-Operative Management (NOM) – STANDARD OF CARE

Indications:

  • Hemodynamically stable
  • No peritonitis
  • No other surgical injury

Components:

  • ICU monitoring
  • Serial Hb, vitals
  • Bed rest
  • Repeat imaging if needed

Success Rate:

  • 90% (even in high-grade injuries)

Adjunct: Angioembolization

Indications:

  • CT contrast blush
  • Ongoing bleeding but stable
  • High-grade injuries

Advantages:

  • Controls arterial bleeding
  • Avoids surgery

 2. Operative Management

Indications 

  • Hemodynamic instability despite resuscitation
  • Peritonitis
  • Failed NOM
  • Associated hollow viscus injury

 Surgical Techniques

1. Perihepatic Packing

  • First-line in damage control surgery
  • Controls venous bleeding

2. Pringle Maneuver

 Temporary occlusion of:

  • Portal vein
  • Hepatic artery

If bleeding stops → hepatic source
If continues → hepatic vein/IVC injury


3. Definitive Procedures

  • Hepatorrhaphy (suturing laceration)
  • Resection (rare)
  • Vascular repair

4. Damage Control Surgery

  • Packing + temporary closure
  • ICU correction (coagulopathy, hypothermia, acidosis)
  • Re-look surgery

 Complications

Early:

  • Hemorrhagic shock
  • Coagulopathy
  • Abdominal compartment syndrome

Late:

  • Bile leak / biloma
  • Liver abscess
  • Hemobilia
  • Pseudoaneurysm

 Follow-Up & Monitoring

  • Serial clinical exam
  • Hb monitoring
  • Repeat CT if:
    • Fever
    • Drop in Hb
    • Suspected complication

 Special ICU Considerations 

  • Avoid over-resuscitation → prevents re-bleeding
  • Balanced transfusion (1:1:1 ratio)
  • Early use of tranexamic acid (within 3 hours)
  • Monitor for abdominal compartment syndrome