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ORIGINAL RESEARCH

E-ISSN :0975-8437

P-ISSN: 2231-2285

Injury pattern, outcomes and management of lIver trauma Imran Ahmed, Shahkamal Hashmi, Farzeen Tanwir, Saadia Ahmed, Muhammad Nadeem

AbSTRACT Aims and Objectives: To determine the major injury patterns, outcomes and management options of liver trauma in a tertiary care setup in Karachi, Pakistan. Materials and Methods: A prospective clinical study that was carried out consisted of 61 patients with liver trauma, 58 males and 3 female, with the mean age 31.46 years. Data regarding age, sex, mode and type of injuries were taken and analyzed. Inclusion criteria included age group equals or more than 13 years of age with diagnosis of liver trauma, patients penetrating and non-penetrating traumatic injury to liver, patients with blunt and sharp injury to liver. Exclusion criteria included all the patients’ less than 13 years of age, patients with pre-existing liver disease i.e. cirrhosis, tumors, hepatitis etc, Patients who have previously undergone hepatic surgery. This study was conducted during the time period of 1st January 2010 till 31st December 2011. The data was analyzed using SPSS 17. Results: The incidence of liver trauma due to non-penetrating injuries was 47(77%) while due to penetrating injuries 14 (23.0%), with a value of p= 0.001. In all cases of blunt injuries, 67.2% patients were presented due to road traffic accidents, and 9.8% patients were due to assaults. In all cases of liver trauma, 08 patients (13%) sustained Grade I liver injury, 27 patients (44.3%) had Grade II liver injury, 20 patients (32.8%) of Grade III liver injuries, 04 (6.6%) patients of Grade IV and 02(3.3%) of Grade V liver injury. 17(27.9%) patients were hemodynamically stable, and managed Medically with strict vital monitoring, input/output charting and repeated examinations. 44(72%) patients were hemodynamically unstable despite aggressive resuscitation and were managed surgically. Conclusion: Non-penetrating liver injuries are most com- mon (77.0%) in our population especially due to road traffic accidents (67.0%). Surgical management has a provital role in saving life where the patient is hemodynamically unstable. Keywords: blunt Injury; Hemodynamically Stable; Liver Trauma; Sharp Injury

Introduction

Trauma is one of the leading causes of mortality worldwide for all age groups. 1 The liver is the largest solid abdominal organ and involves majority of metabolic functions of the body. 2 De- spite the relative protection by overlying ribs, it is susceptible to compressive forces by means of blunt trauma that can in- jure the soft parenchyma. 3,4 Motor vehicle accidents are one of the most frequent causes of traumatic hepatic injury 4 There could be a greater propensity for blunt liver injuries to occur in countries where the driver occupies the right side of the ve- hicle than those where the drivers sits on the left side. Major liver trauma is frequently associated with coagulopathy. 5 The developments in diagnosis, resuscitation and advent of new surgical technique have opened a new chapter in the man- agement of liver injuries. In the past decades the use of CT SCAN has changed the diagnostic and therapeutic approach to such injuries completely, 6 decreasing the options for surgi- cal intervention. The purpose of this study was to document different modes of presentation and treatment of liver trauma of the patients and to document morbidity and mortality of cases included in the study in a tertiary care setting in Karachi from 1 st January 2000 to 31 st December 2001.

Materials and Method

This is a prospective clinical study that was carried out in Jin- nah Postgraduate Medical Centre, Karachi, Pakistan from 1 st January 2010 to 31 st December 2011. It included 61 cases of liver trauma, due to both penetrating and non-penetrating in- juries, on the basis of clinical features and fulfilling inclusion criteria, admitted though accident and emergency depart- ment.

This study included adult patients both male and female. Clin- ical data regarding age, sex, mode and type of injuries were taken and recorded. After initial resuscitation, clinical evalua- tion and thorough examination, those patients who were he- modynamically stable, were admitted to the ward and man- aged conservatively. Ultrasound or CT SCAN was done in all cases managed conservatively. Patients, who were hemody- namically unstable, managed surgically according to grading of liver injury. Resuscitation, treatment options and outcome were recorded on a performa, which was specifically generat- ed for the purpose.

A database was developed on SPSS for window version 17.0

on the basis of questionnaire. For the quantitative variables mean standard deviation (S.D) was calculated and for their comparison t-test was applied. For the qualitative data chi- square test was used where applicable, other wise yates cor- rected chi square was mentioned. Inclusion criteria included age group equals or more than 13 years of age with diagnosis

of liver trauma, all the patients with penetrating and non-pen-

etrating injury to liver, all the patients with blunt and sharp injury to liver. Exclusion criteria included all patients’ less than 13 years of age, patients with pre-existing liver disease i.e. cir- rhosis, tumors, hepatitis etc and patients who have previously undergone hepatic surgery.

Results

The present study consists of 61 patients with hepatic trauma. Thirty patients (49.18%) out of sixty-one, were of liver trauma alone and thirty-one patients (50.81%) of liver trauma with associated injuries. Three patients were female and 58 were male patients with a male to female ratio of 19.3:1.

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E-ISSN :0975-8437

Ahmed et al

P-ISSN: 2231-2285

 

Age

Gender

N

 

Mean + SD

Range

 

Median

Female

3

28.33+ 4.04

24.0-32.0

29.0

Male

58

31.62+ 5.28

18.0-42.0

32.0

Total

61

31.46+ 5.25

 

Table 1. Demographic Distribution

 

Type of Injury

N

Frequency

P

Non- Penetrating

47

77%

P=0.001

 

Penetrating

14

23%

Chi-Square=47.66

Total

61

100%

Table 2. Type of Liver Injury

 

Grade

N

Frequency

Mortality

P

I

8

13.1%

-

P=0.001

II

27

43.3%

-

Chi-Square=47.66

III

20

32.8%

-

IV

4

6.6%

3 (4.9%)

V

2

3.3%

2 (3.3%)

VI

-

-

-

Total

61

100%

5 (8.1%)

Table 3. Grade of Liver Injury

 

Management

 

N

Frequency

Conservative

 

17

27.9%

Surgical

44

72.1%

Total

61

Table 4. Type of Management

 

Surgical Options

 

N

Frequency

95% C.I.

Suturing

18

40.1%

16.1-69.5

Hepatotomy

 

13

29.5%

08.9-58.9

Mesh Wrapping

3

6.88%

0.20-31.5

Perihepatic Packing

-

-

-

Omental Plug

 

8

18.2%

3.3-46.5

Resection

Debridement

2

4.5%

0.0-27.9

Segmental Lobectomy Total

-

-

-

44

72.13%

47.3-89.9

Table 5. Surgical Options for Liver Injury

 

Complications

N

Frequency

Chest Infectiion Jaundice Wound Infection Ext. biliary Fistula Total

27

44.26%

07

11.5%

06

09.8%

09

14.8%

49

Table 6. Complications of Liver Injury

 

The mean age of the patients for female was 28.33+ 4.04 years (mean+ S.D) ranging from 24-32 years with median age of 29, and for male was 31.62+ 5.28 years (mean +S.D) ranging from 18- 42 years with a median age of 32.(Table 1)

In this study, the incidence of liver trauma due to non-pene-

trating injuries was 47(77%) while due to penetrating injuries

14 (23.0%), with a value of p= 0.001 and Chi-Square=47.66.

Out of 47 cases of blunt injuries, 41 patients (67.2%) were

presented due to road traffic accidents with a 95% C.I of 1.19- 31.11, 06 patients (9.8%) were due to assaults with a 95% C.I of 5.35-43.53. Out of 14(23%) patients of penetrating injuries,

12 patients (19.7%) involve to firearm injuries with a 95% C.I

of 5.35-43.58, and 02 patients (3.3%) due to stab injuries with

a 95% C.I of 0.02-20.89. the statistical value were p=0.001 and Chi-Square= 94.21.(Table 2)

Out of a total of 61 patients 08 patients (13%) were of Grade

I liver injury, 27 patients (44.3%) of Grade II liver, 20 patients

(32.8%) of Grade III liver injuries. There were 20 (6.6%) patients of Grade IV and 02(3.3%) of Grade V liver injury. We have not found Grade VI liver injury in our setup. (Table 3). The mortality and morbidity rate in liver trauma varied significantly depend- ing upon the mechanism of injury and impact of injury. both the patients (3.3%) with liver injury of Grade V and 3 out of 4 patients (4.9%) with Grade IV were expired. The 95% C.I was 0.7-27.8.both patients of Grade V liver injury expired during surgery because of complex hepatic injuries. Others two were expired on 3rd and 5th postoperative day due to multi organ failure.

In this study out of a total of 61 patients 17(27.9%) patients were haemodynamically stable, and managed Medically with strict vital monitoring, input/output charting and repeated examination to asses the conditions. 44(72%) patients were haemodynamically unstable despite aggressive resuscitation and were managed surgically. (Table 4)

The choice of different surgical options for securing homeo- stasis in liver trauma depends upon type and mode of injury, grade of liver injury, and clinical assessment. Most of liver inju- ries required simple suture ligation.

Simple suture ligation was done in 18 patients(40%) with a 95% C.I of 16.1-69.5, hepatotomy done in 13 patients(29.8%) with a 95% C.I of 8.9-58.9, absorbable mesh was placed in 03 patients(6.8%) with a 95% C.I of 0.2-31.5, omental patch done in 08 patients(18.2%) with a 95% C.I of 3.3-46.5 and resectional debridement was done in 02 patents(4.5%) with a 95% C.I of

0.0-89.9.

There were 45.9% patients in shock at the time of presenta- tion with increase respiratory rate, pulse rate and decrease

blood pressure. The Res. Rate of the patients in this study had

a mean +S.D of 29.42+ 4.67, ranging 20.0-34.0 with a median

of 31.0. Pulse Rate with a mean + S.D of 119.91-10.1, ranging 98.0-135.0 with a median of 122. Systolic blood pressure in this study was of mean+ S.D. of 87.87, ranging 75.0-110.0 with a median of 85.0. Shock was defined as systolic blood pressure

of 80 mmHg or less. These patients were aggressively resusci- tated with crystalloids, colloids and blood products, and shift- ed to emergency operation theatre for surgery. (Table 5)

Complications developed in patients treated Medically and Surgically. Out of 61 patients, 27 (44.26%) developed chest complication i.e. atelectasis, dry cough, productive cough and pneumonia. 07 patients (11.5%) developed temporary jaundice due to liver injury. Wound infection developed in 06 patients (9.8%) and external biliary fistula developed in 09 pa- tients (14.75%). (Table 6)

Discussion

Trauma is the leading cause of deaths and disability in young people both in developed and developing countries. 1 Injuries with their associated direct and indirect costs results in con- siderable financial burden on the family and relatives. 7,8 Trau- ma has been the major cause of emergency admission in our setup.

The present study consisted of 61 patients with hepatic trau- ma. Thirty patients (49.18%) out of 61, were of liver trauma alone and 31 patients (50.81%) were of liver trauma with associated injuries. Fifty eight patients were male and three were female patients with a male to female ratio of 19.3:1. this shows high male to female ratio compared to other studies because females are mostly non-Ambulant. A study done in Qatar by Faramawy et al, demonstrated male to female ratio of 11.6:1. 9 The reason for this male preponderance is that males are more exposed and projected to trauma than females due to outdoor activities. Another study done in Saudi Arabia by barrimah et al showed almost twice the number of male to female having road traffic accidents ( major cause of traumatic liver injury) in that year. 10

The average age of the patients was 32 for male and 29 for fe- male in our study. In a study done in Italy during 1999 to 2010 by Li Petri et al, the average age was 33 years which is almost equal to the male’s average age. 11

In this study, the incidence of liver trauma due to non-pene- trating injuries was 77% of the cases including 67.2% due to road traffic accidents and 9.8% due to assaults, and the inci- dence of penetrating liver injuries was 23% including 19.7% due to firearm injuries and 3.3% due to stab injuries. The rea- son for high incidence of non-penetrating liver injuries is the reckless driving, unnecessary overtaking, and negligence of traffic law enforcement. Fonsica Neto et al, in a Portuguese study determined that the closed abdominal trauma was the most prevalent amongst all traumas (67.9%), in the penetrat- ing injuries 24.8% were due to firearm. 12

The grades of liver injuries in this study are comparable to other studies. Amongst 90.2% of the all patients which were operated, 13% were of Grade I, 44.3% of Grade II, 32.8% of Grade III liver injuries. There were 6.6% patients of Grade IV and 3.3% of Grade V. We have not found Grade VI liver injury in our setup. In a previous study, there were 68.1% of the pt with hepatic trauma were found to fall in Grade I-III, while only

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Injury pattern, outcomes and management of liver trauma

31.9 were in grade IV- VI. 13Another study done by Zargar and Laal, showed that the frequency of grade I hepatic injury was 27.4%, grade II was 32.1%, grade III was 22.6%, grade IV 8.3%, grade V 4.8% and grade VI 4.8%. Hence the overall incidence for grade I-III was more than 82% of all cases. 13

In

our study 27.9% patients were found to be hemodynamical-

ly

stable, and managed medically with strict vital monitoring,

input/output charting and repeated examination to assess the conditions. 72% patients were haemodynamically unstable despite aggressive resuscitation and therefore were managed surgically. The choice of different surgical options for securing homeostasis in liver trauma depended on type and mode of injury, grade of liver injury and surgeon own discretion.

Most of liver injuries required simple suture ligation. Simple suture ligation was done in 18 patients (40%), hepatotomy done in 13 patients (29.8%), absorbable mesh was placed in three patients (6.8%), omental patch placed in eight patients (18.2%) and resectional debridement was done in two patents (4.5%). According to a study done in Iran, the most frequent option in operated patients with liver trauma was suturing (72.2%), packing was done in 11.1% of the patients, resection and debridement was the choice in 13%, while only 3.7% of the patients underwent Cholecystectomy. 13

There were 45.9% patients in circulatory shock at the time of first presentation, with the systolic blood pressure measuring 80 mmHg or less, these patients were aggressively resuscitat- ed with crystalloids, colloids and blood products, and were prepared for a lapratomy.

Diagnostic peritoneal lavage or four-quadrant tap was not performed in any patient. Anatomical resection and major re- section of complex hepatic injury were not done due to high mortality associated with it.

The mortality and morbidity rate in liver trauma vary signifi- cantly depending upon the mechanism of injury and severity of injury. both the patients with liver injury of Grade V and 3 out of 4 patients with Grade IV expired. both patients of Grade

V liver injury expired during surgery because of complex in-

juries. Others two expired on 3 rd and 5 th postoperative day due to multiorgan failure. Zargar and Laal reported that the mortality rate among the hepatic trauma patients was highest with grade IV-VI which was 80% of the overall mortality rate. Grade II-III accounted for only 20% of the overall mortalities while there was no mortality in grade I hepatic injury. 13 Anoth- er study by bala et al, analyzed the data for only grade III, IV and V hepatic injuries, for which 69% of the adjusted mortality was for grade V hepatic injuries, followed by 29% for grade IV while only 21% with grade III, this showed an extremely high mortality rate for the higher groups notably for grade V. 14 In another study, grade V mortality was found out to be 63.6%, grade IV 26.3%, grade III 5.3%, grade II with 14.7% and no mor- tality with grade I. 15

Complications developed in patients were treated both con- servatively and surgically. Out of 61 patients 27 (44.26%)

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developed chest complication i.e. atelectactesis, dry cough, productive cough and pneumonia. Seven patients (11.5%) de- veloped jaundice, wound infection developed in six patients (9.8%) and external biliary fistula developed in nine patients

(14.75%).

Conclusion

In conclusion, non-penetrating liver injuries are most com- mon (77.0%) in this study population especially due to road traffic accidents (67.0%). Hemorrhage is the leading cause of death in liver trauma. In hemodynamically stable patients, non-operative management is safe and rewarding. Surgical intervention was found to be live saving in hemodynamically unstable patients.

Authors Affiliation

1. Imran Ahmed, MbbS, FCPS, Assistant Professor, Department of Surgery, Ziauddin University, Karachi, Pakistan, 2. Shahkamal Hash- mi, MbbS, MSC, Assistant Professor, Department of Surgery, Ziauddin University, Karachi, Pakistan, 3. Farzeen Tanwir, bDS, PhD, Associate Professor, Department of Postgraduate Studies and Research, Ziaud- din University, Karachi, Pakistan, 4. Saadia Ahmed, MbbS, Assistant Professor, Department of Surgery, Ziauddin University, Karachi, Paki- stan, 5. Muhammad Nadeem bDS, MDS, Department of Periodontol- ogy, Head of Community Dentistry and Periodontology, Liaquat Col- lege of Medicine and Dentistry, Dental block, Darul Sehat Hospital, Karachi, Pakistan.

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How cite this article

Ahmed I, Hashmi S, Tanwir F, Ahmed S, Nadeem M. Injury pattern, outcomes and management of liver trauma. International Journal of Dental Clinics. 2014;6(2):15-18.

Address for Correspondence Dr. Muhammad Nadeem bDS, MDS, Department of Periodontology, Liaquat College of Medicine and Dentistry, Dental block, Darul Sehat Hospital, Karachi, Pakistan. Email: dr_nt01@hotmail.com

Source of Support: Nil Conflict of Interest: None Declared