Liver hepatic trauma

Velmahos, G.C., Toutouzas, K., Radin, R., Chan, L., Rhee, P, Tillou, A., Demetriades, D. High success with nonoperative management of blunt hepatic trauma. The liver is a sturdy organ. Arch. Surg. 2003 138 475-480... 

Portal hypertension is a consequence of increased resistance to blood flow through the portal vein. Increased resistance is usually due to restructuring of intrahepatic tissue (sinusoidal damage) but may also be caused by presinusoidal damage such as portal vein occlusion from trauma, malignancy, or thrombosis. A third (and the least common) mechanism is outflow obstruction of the hepatic vein. This latter damage is posthepatic, and normal liver structure is maintained. This chapter will focus on portal hypertension caused by intrahepatic damage from cirrhosis. 

Rheumatic arthritis, rheumatoid arthritis, trauma, strain, myocardial infarction, angina pectoris, sequelae of cerebrovascular accident, chronic hepatitis, cirrhosis of the liver, enlarged spleen, various tumors, as well as psychiatric disorders. 

Tc-DTPA Arterial perfusion accounts for 20%-40% of the circulation in portal hypertension, cirrhosis causes arterial perfusion to increase to over 60%. In portal vein thrombosis, only an arterial curve is visible. Liver metastasis usually displays relatively high arterial perfusion. In (rare) occlusions of the hepatic artery, only a portal venous curve is visible. When a bolus injection of 400 MBq "Tc-diethylenetriamine pentaacetic acid (DTPA) is applied, scintigraphy is able to reveal a bi-phasic time-activity curve. The initial increase of activity is produced by the arterial influence and the second peak by the portal venous inflow. Both curves can be evaluated quantitatively. (36) Perfusion scintigraphy may be useful in the case of liver trauma, TIPS, hyper-vascularized hepatic tumours and partial liver resection as well as after liver transplantation. 

A female patient between 35 and 40 years of age with confirmed (in line with the methods of the time, including laparoscopy and biopsy) autoimmune hepatitis (ANA ++, SMA+, LMA +, LE factor+, IgG++, y-globulin++, GPT, GOT80-100 Utl, GDH ca. 12 UH, no cholestasis) had been undergoing treatment with prednisolone I azathioprine and had been in constant remission for over 3 years (maintenance dose of 4—6 mg prednisolone and 50 mg azathioprine for over 2 years). Physically and mentally stable, engaged in her profession, she had placed great confidence in us. Approximately 3 days after a sudden, severe emotional trauma with mental breakdown, the AlH deteriorated on a massive scale, and about 3 weeks later, the patient died in a coma hepaticum from acute liver failure. 

Due to the dual blood supply to the liver, patients withblunthepaticinjuries (BHI) are ideal candidates for TAE, with success percentages of TAE reported to be as high as 98%. Complication rates of hepatic TAE are low, although one must keep in mind that necrosis can occur if portal venous supply is also disrupted due to trauma. In a retrospective study of 21 paediatric trauma patients with BHI, 18 patients could be managed conservatively, two of whom successfully underwent TAE in order to stop haemorrhage (Ohtsuka et al. 2003). 

Fig. 23.1a-d. Liver trauma in a 15-year-old boy. a CT-scan revealed the presence of an arterial pseudoaneurysm, b Selective catheterization of the hepatic artery confirmed the pseudoaneurysm, c With a coaxial system (Tracker Renegade) we overpass the pseudoaneurysm and occlude the exit branch with a coil. Then, we occlude the pseudoaneurysm with glue followed by the occlusion of the afferent artery by a coil, d Control angiogram revealed a complete occlusion of the pseudoaneurysm... 

Hepatic hematoma is a lesion characterized by bleeding inside the liver parenchyma, under the capsule, with or without free rupture. Surgery and trauma are the two most common causes of hepatic bleeding. Hemorrhage within a solid liver neoplasm, especially a hepatocellular adenoma, is a third well-known mechanism by which intra- or perihepatic hematoma can be induced (Casillas et al. 2000). Symptomatic manifestations depend on the severity of the bleeding, the location, and the time frame during which the hemorrhage occurred. 

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