Liver Trauma

Liver Trauma Imaging: Overview, Radiography, Computed Tomography http://emedicine.medscape.
com/article/370508-overview#showall
Liver Trauma Imaging

Updated: Jun 08, 2017
Author: Ali Nawaz Khan, MBBS, FRCS, FRCP, FRCR; Chief Editor: John Karani, MBBS, FRCR
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OVERVIEW
Overview
The liver is the largest solid abdominal organ with a relatively fixed position, which makes it prone
to injury. The liver is the second most commonly injured organ in abdominal trauma, but damage to
the liver is the most common cause of death after abdominal injury (see the images below). The
most common cause of liver injury is blunt abdominal trauma, which is secondary to motor vehicle
accidents in most instances.
In the past, most of these injuries were treated surgically. However, surgical literature confirms that
as many as 86% of liver injuries have stopped bleeding by the time surgical exploration is
performed, and 67% of operations performed for blunt abdominal trauma are nontherapeutic.
Philipoff et al have proposed that a stiff, cirrhotic liver may represent an important risk factor for
blunt gallbladder injury. Almost all gallbladder injuries following blunt trauma are associated with
other significant intra-abdominal injuries, and in the setting of acute trauma, the authors
recommend an open procedure to facilitate exploration to rule out associated injuries.
Cholecystectomy remains the definitive management for gallbladder trauma. Gallbladder rupture is
seen in less than 1% of cases of blunt abdominal trauma. [1]
Conservative, nonoperative management has become the treatment of choice for blunt hepatic
trauma in hemodynamically stable patients. The increased use of nonoperative management has
been facilitated by advancements such as higher-resolution CT, increased availability of
interventional procedures such as angiography and embolization, image-guided percutaneous
drainage, and endoscopy. Such advancements have also helped to quickly identify the need for
urgent laparotomy and attention to visceral and vascular injuries. [2] Almost 80% of adults and 97%
of children are treated conservatively by using careful follow-up imaging studies. [3, 4, 5, 6, 7]
For hepatic lesions that are grade 1 through 3, according to the American Association for the
Surgery (AAST) (see below), nonoperative management is indicated if there is no injury to
abdominal organs. Surgical intervention is required for any lesions higher than grade IV in which
there is hemorrhagic risk or recurrence. [6]
AAST Liver Trauma Classification
The AAST has classified liver trauma injuries as follows [8, 6, 9] :
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Liver Trauma Imaging: Overview, Radiography, Computed Tomography http://emedicine.medscape.com/article/370508-overview#showall
Grade I: hematoma: subcapsular <10% surface area; laceration: capsular tear <1 cm
parenchymal depth.
Grade II: hematoma: subcapsular 10-50% surface area; intraparenchymal <10 cm diameter;
laceration: capsular tear 1-3 cm parenchymal depth, <10 cm in length.
Grade III: hematoma: subcapsular >50% surface area of ruptured subcapsular or
parenchymal hematoma; intraparenchymal hematoma >10 cm or expanding; laceration: >3
cm parenchymal depth.
Grade IV: laceration: parenchymal disruption involving 25-75% hepatic lobe or 1-3 Couinaud
segments.
Grade V: laceration: parenchymal disruption involving >75% of hepatic lobe or >3 Couinaud
segments within a single lobe; vascular: juxtahepatic venous injuries (ie, retrohepatic vena
cava/central major hepatic veins).
Grade VI: hepatic avulsion.
The World Society of Emergency Surgery (WSES) has presented the following classifications
utilizing the AAST grading system [8, 10] :
Grade I (minor hepatic injury): AAST grade I-II hemodynamically stable either blunt or
penetrating lesions.
Grade II (moderate hepatic injury): AAST grade III hemodynamically stable either blunt or
Grade III (severe hepatic injury): AAST grade IV-VI hemodynamically stable either blunt or
Grade IV (severe hepatic injury): AAST grade I-VI hemodynamically unstable either blunt or
Preferred examination
Plain radiographic findings are nonspecific, but they may be useful in showing the extent of
associated skeletal trauma. Contrast-enhanced CT scanning remains the examination of choice in
patients with blunt abdominal trauma. [11, 12, 13, 14, 15, 5, 16]
Radionuclide study with technetium-99m (99mTc) iminodiacetic acid (IDA) is the examination of
choice in patients in whom bile leaks are suspected. Magnetic resonance imaging (MRI) has yet to
find a role but can be used to monitor liver injury. Magnetic resonance cholangiopancreatography
(MRCP) may be used for the diagnosis and follow-up observation of bile duct injuries. [17]
Angiography is useful in localizing the site of hemorrhage and in providing an opportunity for the
interventional radiologist to proceed to transcatheter embolization of bleeding sites.
The original guidelines of Practice Management for Nonoperative Management of Blunt Injury to
the Liver and Spleen (Eastern Association for the Surgery of Trauma guideline) remain valid,
supported by the accumulation of a large amount of data. Stassen et al reviewed 176 papers, of
which 94 were used to create the current practice management guideline for the selective
nonoperative management of blunt hepatic injury. [18]
The review concluded that nonoperative management of blunt hepatic injuries currently is the
treatment modality of choice in hemodynamically stable patients, irrespective of the grade of injury
or patient age. However, nonoperative imaging of blunt trauma should only be considered when
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reliable monitoring, serial clinical evaluations, and an operating room available for urgent
laparotomy are readily available. Patients who are hemodynamically unstable and have peritonitis
still warrant emergent operative intervention. Ready availability of CT, angiography, percutaneous
drainage, ERCP, and laparoscopy remain important adjuncts to nonoperative management of
hepatic injuries. [18]
The authors add that despite the explosion of literature on this topic, many questions regarding
nonoperative management of blunt hepatic injuries remain without conclusive answers in the
literature. [18]
Grade 1 hepatic injury in a 21-year-old man with a stabbing injury to the right upper quadrant of the abdomen.
Axial, contrast-enhanced computed tomography (CT) scan demonstrates a small, crescent-shaped
subcapsular and parenchymal hematoma less than 1 cm thick.
View Media Gallery
Grade 1 hepatic injury in a 21-year-old man with a stabbing injury to the right upper quadrant of the abdomen.
Diagram of the CT scan in the previous image.
View Media Gallery
For more information, see Blunt Abdominal Trauma in Emergency Medicine, Penetrating
Abdominal Trauma in Emergency Medicine, and Penetrating Abdominal Trauma.
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Limitations of techniques
Plain radiographs cannot depict liver trauma directly, and radiographic findings may be completely
normal. In penetrating abdominal trauma, overall sensitivity of focused ultrasonography is 46%, and
specificity is 94%. [19] Emergency ultrasonographic findings based on the demonstration of free
fluid and/or parenchymal injury demonstrate the overall sensitivity of ultrasonography for detection
of blunt abdominal trauma to be 72%. However, the sensitivity is higher (98%) for injuries of grade
3 or higher. However, negative ultrasonographic findings do not exclude hepatic injury.
Angiographic images can fail to depict active bleeding, and false-negative or false-positive
diagnoses can occur with liver trauma.
Radiography
Plain radiographs are usually the first radiologic examination performed in patients in whom liver
trauma is suspected. Radiographs may initially depict opaque foreign bodies, such as bullets or
shrapnel. Plain radiographic findings are nonspecific, but they are useful in evaluating rib and
spinal injuries in patients with blunt abdominal trauma. Fractures of the right lower ribs should
suggest the possibility of underlying liver injury. Pneumoperitoneum, major diaphragmatic injury,
gross organ displacement, and metallic foreign bodies may be identified. [20] Because plain
radiography is performed in a traumatized patient, an optimal-quality radiograph is not always
possible. Fractures and a pneumoperitoneum may be missed.
Computed Tomography
CT scanning, particularly contrast-enhanced CT scanning, is accurate in localizing the site and
extent of liver injuries and associated trauma, providing vital information for treatment in patients.
[11, 12, 5, 16] Spiral CT scanning is the preferred scanning technique, if available. Multidetector-row
CT scanning offers the further advantages of fast scanning times (allowing scanning during specific
phases of intravenous contrast enhancement) and the acquisition of thin sections over a large area
(allowing high-quality multiplanar reconstruction). [21] CT scanning without intravenous contrast
enhancement is of limited value in hepatic trauma, but it can be useful in identifying or following up
a hemoperitoneum.
CT scans can be used to monitor healing. Trauma to the liver may result in subcapsular or
intrahepatic hematoma, contusion, vascular injury, or biliary disruption. [22] CT scan criteria for
staging liver trauma based on the AAST liver injury scale include the following:
Grade 1 - Subcapsular hematoma less than 1 cm in maximal thickness, capsular avulsion,

superficial parenchymal laceration less than 1 cm deep, and isolated periportal blood tracking
(see the images below)
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Grade 1 hepatic injury in a 21-year-old man with a stabbing injury to the right upper quadrant of the
abdomen. Axial, contrast-enhanced computed tomography (CT) scan demonstrates a small, crescent-
shaped subcapsular and parenchymal hematoma less than 1 cm thick.
View Media Gallery
Grade 1 hepatic injury in a 21-year-old man with a stabbing injury to the right upper quadrant of the
abdomen. Diagram of the CT scan in the previous image.
View Media Gallery

Grade 2 - Parenchymal laceration 1-3 cm deep and parenchymal/subcapsular hematomas
1-3 cm thick (see the images below)
A 20-year-old man with systemic lupus erythematosus presented with grade 2 liver injury after minor
blunt abdominal trauma. Nonenhanced axial CT scan at the level of the hepatic veins shows a
subcapsular hematoma 3 cm thick.
View Media Gallery
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blunt abdominal trauma. Diagram of the CT scan in the previous image.
View Media Gallery
blunt abdominal trauma (same patient as in the previous 2 images). Axial CT image through the inferior
aspect of the right lobe of the liver demonstrates multiple low-attenuation lesions in the liver consistent
with parenchymal contusion.
View Media Gallery
blunt abdominal trauma (same patient as in the previous 3 images). Diagram of the CT scan in the
previous image.
View Media Gallery
Grade 3 - Parenchymal laceration more than 3 cm deep and parenchymal or subcapsular
hematoma more than 3 cm in diameter (see the images below)
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Grade 3 liver injury in a 22-year-old woman after blunt abdominal trauma. Contrast-enhanced axial CT
scan through the upper abdomen shows a 4-cm-thick subcapsular hematoma associated with
parenchymal hematoma and laceration in segments 6 and 7 of the right lobe of the liver. Free fluid is
seen around the spleen and left lobe of the liver consistent with hemoperitoneum.
View Media Gallery
Grade 3 liver injury in a 22-year-old woman after blunt abdominal trauma. Diagram of the CT scan in the
previous image.
View Media Gallery
Grade 4 - Parenchymal/subcapsular hematoma more than 10 cm in diameter, lobar
destruction, or devascularization (see the images below)
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Image obtained in a 35-year-old male bouncer after blunt abdominal injury. Nonenhanced axial CT scan
of the abdomen demonstrates a large subcapsular hematoma measuring more than 10 cm. The high-
attenuating areas within the lesion represent clotted blood. The injury was classified as a grade 4 liver
injury.
View Media Gallery
Image in a 35-year-old male bouncer after blunt abdominal injury (same patient as in the previous
image). Diagram of the CT scan in Image above.
View Media Gallery
Contrast-enhanced axial CT scan in a 39-year-old man with a grade 4 liver injury shows a large
parenchymal hematoma in segments 6 and 7 of the liver with evidence of an active bleed. Note the
capsular laceration and large hemoperitoneum.
View Media Gallery
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Diagram of the CT scan in Image above in a 39-year-old man with a grade 4 liver injury shows a large
parenchymal hematoma in segments 6 and 7 of the liver with evidence of an active bleed.
View Media Gallery
Multisegment infarct (segments 2, 3, 4a, and 4b) in a 40-year-old man who was in a motor vehicle
accident and underwent emergency segmental resection of the right lobe. Note the sharply demarcated
wedge-shaped area of infarction; hence, the classification as grade 4.
View Media Gallery
Multisegment infarct (segments 2, 3, 4a, and 4b) in a 40-year-old man who was in a motor vehicle
accident and underwent emergency segmental resection of the right lobe. Diagram of the CT scan in the
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previous image.
View Media Gallery
Grade 5 - Global destruction or devascularization of the liver (see the images below)
Grade 5 injury in a 36-year-old man who was involved in a motor vehicle accident demonstrates global
injury to the liver. Bleeding from the liver was controlled by using Gelfoam.
View Media Gallery
Grade 5 injury in a 36-year-old man who was involved in a motor vehicle accident. Diagram of the CT
scan in the previous image.
View Media Gallery
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Grade 5 injury in a 36-year-old man who was involved in a motor vehicle accident (same patient as in
the 2 previous images). Axial CT scan shows a hematoma around the right kidney and inferior vena
cava consistent with renal and inferior vena cava injury.
View Media Gallery
Grade 5 injury in a 36-year-old man who was involved in a motor vehicle accident (same patient as in
the previous 3 images). Diagram of the CT scan in the previous image.
View Media Gallery
Grade 6 - Hepatic avulsion
Subcapsular hematoma
Subcapsular hematoma is usually seen in a lenticular configuration; most subcapsular hematomas

are anterolateral to the right lobe of the liver. Subcapsular hematomas cause direct compression
and deformity of the shape of the underlying liver.
On nonenhanced CT scans, the liver appears hyperattenuating compared with a subcapsular

hematoma. [23] On enhanced CT scans, a subcapsular hematoma appears as a low-attenuating,
lenticular collection between the liver capsule and the enhancing liver parenchyma.
Unless bleeding recurs, attenuation of the subcapsular hematoma decreases with time.
Subcapsular hematomas resolve within 6-8 weeks.
Intraparenchymal hematomas
On contrast-enhanced CT scans, acute hematomas appear as irregular, high-attenuation areas,

which represent clotted blood, surrounded by low-attenuating unclotted blood or bile. Over time, the
attenuation of the hematoma is reduced, and the hematoma eventually forms a well-defined serous
fluid collection that may expand slightly. A focal, intrahepatic, hyperattenuating area with
attenuation of 80-350 HU may represent an active hemorrhage or pseudoaneurysm.
Focal or diffuse periportal low attenuation is believed to be secondary to tracking of blood around
the portal vessels, although other possibilities include bile leaks, edema, and dilated periportal
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lymphatics resulting from increased central venous pressure or injury to the lymphatics.
A low-attenuating periportal collar is seen in children with nonhepatic blunt abdominal trauma and
also in the absence of intra-abdominal injury. Thus, without other ancillary findings within the liver,
the presence of a low-attenuating periportal collar is not indicative of hepatic injury. However, the
presence of this sign in documented abdominal trauma correlates with the severity of trauma,
physiologic instability, and a higher mortality rate.
CT scan findings in approximately 25% of children with blunt abdominal trauma show periportal low
attenuation. That only 40% of these children have evidence of liver injury has been shown.
Laceration
Laceration of the liver appears as a nonenhancing linear or branching structure, usually at the liver
periphery. Acute lacerations have a sharp or jagged margin, but with time, lacerations may enlarge,
and the margins may develop rolled edges.
Multiple parallel lacerations occur as result of compressive forces (bear claw lacerations).
Lacerations may communicate with hepatic vessels and/or biliary radicles.
Vascular injuries
Injuries to the major hepatic veins and the retrohepatic inferior vena cava are uncommon after blunt
abdominal trauma.
Retrohepatic vena caval injuries are suggested on CT scans when lacerations extend into the
major hepatic veins and the inferior vena cava or when profuse retrohepatic hemorrhage extends
into the lesser sac or near the diaphragm.
Perihilar liver tissue may become partially devascularized by a deep laceration or complete
avulsion of the dual hepatic blood supply. These devascularized areas of the liver appear as
wedge-shaped regions extending toward the liver periphery, and they fail to enhance after the
administration of contrast material.
Pseudoaneurysms are better depicted by using spiral or multisection CT scanning because of the
ability to image during peak contrast enhancement.
Acute hemorrhage
Acute, intrahepatic hemorrhage is seen as irregular areas of contrast agent extravasation.
Measurement of attenuation values is useful in differentiating extravasated contrast from

hematoma. Extravasated contrast material has an attenuation value of 85-350 HU (mean, 132 HU),
whereas hemorrhage has an attenuation value of 40-70 HU (mean, 51 HU).
CT scans can be useful in depicting recurrent bleeding after surgery or radiologic intervention.
Gallbladder injury
Gallbladder injury is uncommon, occurring in 2-8% patients with blunt liver trauma. Prior to the
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availability of CT scanning and ultrasonography, gallbladder injuries were rarely diagnosed before
surgery. [24]
CT findings in gallbladder injuries include ill-defined or irregular wall contour, pericholecystic or

subserosal fluid, collapsed gallbladder, wall thickening, intraluminal blood, free intraluminal mucosal
flap, contrast enhancement of the gallbladder wall or mucosa, free intraperitoneal fluid iso-
attenuating with bile, mass effect on the duodenum, and displacement of the gallbladder toward the
midline.
Biloma and bile peritonitis
As a result of the slow rate of leaking, a biloma may take weeks or months to develop after trauma;
hence, it usually is diagnosed by using follow-up scans. CT scan findings of a posttraumatic biloma
demonstrate a cystic structure of low attenuation in or around the liver. Bilomas may contain debris
or septa.
Bile peritonitis is an uncommon complication of blunt liver trauma. CT scan findings of bile
peritonitis include persistence or increasing amounts of low-attenuating, free peritoneal fluid and
thickening of a peritoneum that shows evidence of enhancement.
Degree of confidence
CT scanning is the mainstay of diagnosis of hepatic injuries following blunt trauma; initial CT scan
findings help in determining the type of treatment required. With the use of high-speed, spiral CT
scans, predicting the necessity of operative treatment or angiography is possible in patients with
blunt hepatic injury before deterioration of their hemodynamic state.
A finding of pooled contrast material within the peritoneal cavity indicates active and massive
bleeding; patients with this finding may require emergency surgery. [25] Intrahepatic pooling of
contrast material with an intact liver capsule usually indicates a self-limiting hemorrhage; most
patients with this finding can be treated conservatively.
CT scanning has been proven to be extremely useful in helping to make therapeutic decisions in
hepatic trauma and in helping to reduce laparotomy rates in as many as 70% patients at the time of
initial evaluation.
False positives/negatives
False-positive errors in the diagnosis of liver injury with CT scans may occur as a result of beam-
hardening artifacts from adjacent ribs, which can mimic contusion or hematoma. An air-contrast
level within the stomach in a patient with a nasogastric tube can produce streak artifacts throughout
the left lobe of the liver; these may mimic intrahepatic lacerations and/or hemorrhage. The nature of
these artifacts can be confirmed if the patient is scanned in a decubitus position.
False-negative findings may occur in the setting of a fatty liver only when contrast-enhanced CT
scans are obtained. On these images, the enhanced fatty liver may become iso-attenuating relative
to the laceration or hematoma. In this situation, a nonenhanced CT scan may provide useful
information regarding hepatic injury. Focal fatty infiltration may also mimic hepatic hematoma,
laceration, or infarction. Hepatic lacerations with a branching pattern can mimic nonopacified portal
or hepatic veins or dilated intrahepatic bile ducts. Careful evaluation of all branching intrahepatic
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structures is important, and the diagnosis is made with serial images to differentiate the various
structures.
Small amounts of free intraperitoneal blood or fluid in the perihepatic space may mimic a
subcapsular hematoma; however, these fluid collections usually do not compress the liver
parenchyma. CT scans do not always help in predicting which patients require laparotomy. [26]
Hematomas or hemorrhage within the liver can occur with a nontraumatic etiology.
In the evaluation of recurrent hepatic bleeding, particularly after an angiographic intervention,

nonenhanced and enhanced scans are important to distinguish extravasated contrast material
during angiography from recurrent, ongoing hemorrhage. Other hepatic lesions that may mimic
active bleeding on CT scans include calcified liver masses and hemangiomas.
Magnetic Resonance Imaging

MRI has a limited role in the evaluation of blunt abdominal trauma, and it has no advantage over
CT scanning. Theoretically, MRI can be used in follow-up monitoring of patients with blunt
abdominal trauma, and the modality may be useful in young and pregnant women with abdominal
trauma in whom the radiation dose is a concern. [27]
MRCP has been used in the assessment of pancreatic duct trauma and its sequelae, and it can be
used to image biliary trauma. [17] Another potential use of MRI is in patients with renal failure and in
patients who are allergic to radiographic contrast medium.
Ultrasonography
Ultrasonograms can demonstrate a number of traumatic lesions, such as hematomas, contusions,
bilomas, and hemoperitoneum. [28, 29]
For ultrasonograms of liver trauma, see the images below.
Sonogram of the liver in a 62-year-old woman with a history of recent liver biopsy. The scan shows a loculated
anechoic collection in the liver; whether this finding represents a biloma or a hematoma is not clear on this
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scan.
View Media Gallery
Abdominal sonogram in a 35-year-old male bouncer after blunt abdominal injury shows a crescent-shaped
hyperechoic collection along the right lateral aspect of the liver consistent with subcapsular hematoma.
View Media Gallery
Hepatic hematomas are grouped into 3 categories, as follows:
Rupture into the liver and its capsule

Separation of the capsule by a subcapsular hematoma
Central hepatic ruptures
A subcapsular hematoma usually appears as a curvilinear fluid collection; its echogenicity varies
with age. Initially, hematomas are anechoic, becoming progressively more echogenic over the
course of 24 hours. With the passage of time, echogenicity of the hematoma once again begins to
decrease, and within 4-5 days, the hematoma becomes hypo-echoic or anechoic.
Septa and internal echoes often develop within the hemorrhagic collection by 1-4 weeks.
Appearances of hepatic laceration change with time. Lacerations appear slightly echogenic,
becoming hypoechoic or cystic when scanned days after the injury.
Similar to hematomas, contusions usually are hypoechoic initially, becoming transiently

hyperechoic and then hypoechoic. The most common ultrasonographic pattern observed with liver
parenchymal injuries is a discrete hyperechoic area; however, a diffuse hyperechoic and
occasionally a discrete hypoechoic pattern may be observed. [23, 28]
An echogenic clot often is seen surrounding the liver, and hypoechoic fluid may be observed in
other parts of the abdomen.
Bilomas appear as rounded or ellipsoid, anechoic, loculated structures that are fairly well defined in
close proximity to the liver and bile duct. Diaphragmatic ruptures appear as a discontinuous line of
echoes.
A number of studies have suggested that ultrasonography can replace the invasive procedure of
peritoneal lavage in the evaluation of blunt abdominal trauma.
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Focused assessment performed by using ultrasonography in patients with liver trauma is still
investigational for evaluation of blunt and penetrating abdominal trauma. [29] The primary
advantage is immediate availability in emergency departments. Some centers use ultrasonography
as the initial examination. Patients who are unstable and have a large amount of fluid detected on
ultrasonograms are immediately transported for surgery. In addition, patients at these centers who
are stable and who have a large amount of intra-abdominal fluid also may be immediately treated
with surgery.
An alternative approach is followed in other centers. If ultrasonographic findings are positive for
intra-abdominal fluid, CT scanning is the next step. If fluid is not demonstrated on abdominal
ultrasonograms, the patient is observed for 12 hours; however, if abdominal pain persists, the
patient undergoes CT scanning.
Ultrasonography is the initial examination of choice in the pediatric age group because of the
modality's nonionizing and noninvasive nature. Ultrasonography is particularly useful in imaging
neonates who are ill and in whom the clinical condition is too unstable to allow transport to a CT
scanning facility but who may have a hepatic hematoma after a traumatic delivery or resuscitative
efforts.
In a neonate with a decreasing hematocrit level and increasing abdominal distension,

ultrasonography may rapidly help in confirming a diagnosis of liver trauma. Because most children
with hepatic trauma are treated conservatively, most children can be monitored by using
ultrasonography.
Ultrasonography has several advantages over peritoneal lavage in the diagnosis of blunt abdominal
trauma. Ultrasonography is a noninvasive procedure that is readily available at the patient's
bedside and is less expensive to perform than is peritoneal lavage. However, although
ultrasonography may be useful in most patients with blunt abdominal trauma, pitfalls remain.
Injury to the liver, especially at the dome or lateral segment of the left lobe of the liver, can easily be
missed with ultrasonography, particularly in the presence of ileus or when pain makes the
examination difficult. The sensitivity of ultrasonography in the detection of free abdominal fluid
associated with bowel or mesenteric injury has been reported as only 44%. Blunt abdominal injury
may involve organs other than the liver, and these injuries must be detected reliably.
Ultrasonograms may not directly depict injuries to the bowel, mesentery, pancreas, diaphragm,
adrenal gland, and bone. Ultrasonography is probably limited in the detection of many vascular
injuries as well. A hepatic laceration may be initially difficult to detect, but it may become obvious
with the passage of time.
Hepatic hemorrhage may occur as a result of causes other than trauma, including sickle cell
anemia, liver tumors, coagulopathies, organ phosphate toxicity, and collagen vascular disease. It
may also occur in patients receiving long-term hemodialysis. Hepatic hemorrhage and rupture may
occur in eclampsia, pre-eclampsia during the third trimester of pregnancy, HELLP syndrome
(hemolysis, elevated liver enzymes, low platelets), hepatic adenoma, and hepatocellular
carcinoma.
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Nuclear Imaging
Prior to the widespread availability of CT scanning, technetium-99m (99mTc) sulfur colloid or 99mTc-
labeled denatured red blood cell studies were widely used in the evaluation of patients with blunt
hepatic and splenic trauma. The primary limitations of radionuclides are the nonspecific findings
and an inability to evaluate other intraperitoneal and retroperitoneal organs. Despite the
disadvantages, radionuclide techniques can offer an important imaging alternative in patients in
whom CT scanning cannot be performed, such as those patients in whom the use of intravenous
and oral contrast is contraindicated, those who cannot hold their breath, and those who have
metallic objects or surgical clips in the abdominal cavity (see the images below).
A 62-year-old woman with a history of recent liver biopsy. Technetium-99m iminodiacetic acid (IDA) scan
obtained immediately after the injection of the radioisotope shows a large filling defect in the liver, which
showed subsequent filling in the 4-hour image consistent with biloma.
View Media Gallery
Technetium-99m iminodiacetic acid (IDA) scan in a 30-year-old man who sustained liver injury in a motor
vehicle accident. The scan was obtained 1 month later and shows extravasation of the isotope from the biliary
tract; this is consistent with a bile leak. Note the relative photon deficiency of the right lobe, which is due to
liver contusion.
View Media Gallery
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Patients who have documented evidence of hepatic or splenic trauma can be monitored
noninvasively by using 99mTc sulfur colloid scanning. Most patients with liver trauma show complete
or partial resolution of the colloid defects over a period of 3-6 months. However, defects within the
spleen may persist indefinitely and do not necessarily indicate a poor prognosis. Whether defects in
the liver have similar connotations is uncertain.
After splenic rupture, splenic tissue can become implanted in the peritoneal or intrathoracic cavities
(splenosis). Splenosis may be difficult to differentiate from other masses, such as
lymphadenopathy, on subsequent scans obtained by using cross-sectional imaging, particularly
when scans are performed remote in time from the injury. Uptake with 99mTc sulfur colloid or9 9m Tc-
labeled denatured red cells provides a tissue-specific diagnosis of ectopic splenic tissue.
Labeled red cells may be used to detect the site of active intraperitoneal or retroperitoneal
hemorrhage, although quantitating the size of the hemorrhage is difficult using this technique.
Bile duct and/or gallbladder injuries occur in 5% of patients with blunt abdominal trauma. Moreover,
biliary injuries may not be identified pre-operatively or may remain unidentified for weeks or months
after trauma.
Although CT scanning remains the examination of choice in the evaluation of liver trauma, the
procedure of choice to evaluate bile leaks is 99mTc iminodiacetic acid (IDA) scanning. CT scanning
and ultrasonography can help to detect intra-abdominal fluid, but differentiation between loculated
ascitic fluid and hematoma, abscess, and biloma may not be always possible. Scanning for 99mTc
IDA uptake usually is performed as a dynamic study immediately after the injection of the
radionuclide. The angiographic phase can provide important information regarding vascular injuries
and associated renal injury, which may subsequently be missed on static scans.
Following the dynamic study, a 20-min static scan of the liver is obtained in several planes; in
appropriate circumstances, scans can be obtained for as long as 24 hours.
Bile leaks are demonstrated as extravasated activity shortly after administration of the radionuclide.
Bilomas are demonstrated initially as a photon-deficient mass that shows activity on delayed scans.
In the detection of bilomas, delayed images are essential (2-24 hr); otherwise bilomas may be
missed.
In patients with blunt trauma, there is an inability to evaluate other sites of abdominal injury and to
quantitate intraperitoneal and retroperitoneal hemorrhage. However, in patients in whom a bile leak
or biloma is suspected, 99mTc IDA uptake imaging is the examination of choice; this provides a
noninvasive technique for arriving at a specific diagnosis.
Focal defects identified with 99mTc sulfur colloid scanning or in the angiographic/hepatic phase of
99mTc IDA scanning may not be related to the trauma; these defects may instead represent simple
liver cysts, granulomas, pseudotumors, abscesses, or tumors unrelated to trauma. If delayed scans
are not performed, bilomas and bile leaks may be missed using 99mTc IDA scans. Delayed imaging
not only provides time for the activity to accumulate within the biloma but also allows clearing of the
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isotope from the liver, increasing the target-to-background ratio of activity.
Angiography
Most patients with liver trauma who present to the emergency department in shock have positive
results after peritoneal lavage and require immediate laparotomy to control hemorrhage.
Angiography has no role in the evaluation of these patients. However, patients with less severe
trauma may be difficult to evaluate at clinical examination and at laparotomy.
If the patient is stable, cross-sectional imaging may provide sufficient detail to treat the patient
conservatively. A dynamic angiographic study may demonstrate the site of active bleeding,
providing an opportunity for transcatheter embolization, which may be the only treatment required
(see the images below).
Selective celiac arteriogram of a grade 1 hepatic injury in a 21-year-old man with a stabbing injury to the right
upper quadrant of the abdomen. The image shows a focal area of hemorrhage in the right lobe of the liver
(arrow) due to the stabbing injury. The well-demarcated filling defect seen in the lateral aspect of the right lobe
of the liver is due to compression of normal liver parenchyma by the subcapsular hematoma.
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Postembolization selective arteriogram of a grade 1 hepatic injury in a 21-year-old man with a stabbing injury
to the right upper quadrant of the abdomen (same patient as in the previous image). The image shows
cessation of the bleeding in the right lobe of the liver.
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A 20-year-old man with systemic lupus erythematosus presented with grade 2 liver injury after minor blunt
abdominal trauma. Selective celiac artery arteriogram shows multiple microaneurysms due to systemic lupus
erythematosus. Note the parenchymal filling defects due to contusion and medial displacement of the right
liver margin due to subcapsular hematoma.
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Liver contusion
Angiographic findings in patients with liver contusion include the following:
Stretching and elongation of arterial branches around an avascular mass may be observed.
Delay in hepatic blood flow to the involved segments may occur.
A transient attenuation difference in uninvolved segments may be depicted.
Mottled accumulation of contrast material in the parenchymal phase may be noted.
The portal venous phase may confirm a parenchymal defect.
Peripheral portal venous filling may be unusually well demonstrated in the presence of
contusions.
Liver lacerations
Angiographic findings in patients with liver lacerations include the following:
Arterial collaterals may bypass arterial occlusions.
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Contrast material extravasation may occur.

Discrete lacerations may appear as linear or complex lucent defects.
Intrahepatic hematomas may appear as poorly defined lucent defects.
Arterioportal fistulas may be obvious.
Contrast material may pass into the biliary tree, identifying the site of hemobilia.
Subcapsular hematoma
Angiographic findings in patients with subcapsular hematoma include the following:
Subcapsular hematomas compress normal parenchyma and may appear as sharply defined,
lucent defects against the increased contrast accumulation in the compressed parenchyma.
Arterial displacement may be seen.
Contrast material extravasation may occur.
High-velocity bullet injuries
Angiographic findings in patients with high-velocity bullet injuries include the following:
High-velocity bullets tend to cause burst injuries with distant contusions and parenchymal
disruption.
Occasionally, these injuries are associated with aortic and renal injuries.
All of the angiographic findings of blunt liver trauma can be seen in this group of patients.
Low-velocity penetrating injuries (stab wounds, liver biopsy, and biliary

drainage TIPS procedure)
Angiographic findings in patients with low-velocity penetrating injuries include the following:
Arterial aneurysms and arterial pseudo-aneurysms

Arteriovenous fistulas
Hematomas
Evaluating the extent of liver injury at surgery may be difficult; in fact, identifying the lesion within
the liver may occasionally be impossible. Emergency hepatic angiography should be performed if
at all feasible, because it not only documents the injury and helps to evaluate complications, such
as pseudo-aneurysms, subcapsular hematoma, or hemobilia, it also provides access for
transcatheter embolization.
Although angiography is useful in selected patients, false-positive and false-negative results occur
in patients with hepatic trauma.
Liver rupture may be spontaneous or may occur as result of liver tumors, HELLP syndrome, simple
cysts, amebic abscess, and hydatid cysts. Intrahepatic arterial aneurysms may be congenital or
may be related to vasculitides.
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Liver Trauma

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Liver Trauma

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Liver Trauma Imaging: Overview, Radiography, Computed Tomography http://emedicine.medscape.

Liver Trauma Imaging

AAST Liver Trauma Classification

The AAST has classified liver trauma injuries as follows [8, 6, 9] :

Grade 1 - Subcapsular hematoma less than 1 cm in maximal thickness, capsular avulsion,

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Subcapsular hematoma is usually seen in a lenticular configuration; most subcapsular hematomas

On nonenhanced CT scans, the liver appears hyperattenuating compared with a subcapsular

On contrast-enhanced CT scans, acute hematomas appear as irregular, high-attenuation areas,

Acute, intrahepatic hemorrhage is seen as irregular areas of contrast agent extravasation.

Measurement of attenuation values is useful in differentiating extravasated contrast from

CT findings in gallbladder injuries include ill-defined or irregular wall contour, pericholecystic or

Biloma and bile peritonitis

In the evaluation of recurrent hepatic bleeding, particularly after an angiographic intervention,

Magnetic Resonance Imaging

For ultrasonograms of liver trauma, see the images below.

Hepatic hematomas are grouped into 3 categories, as follows:

Rupture into the liver and its capsule

Similar to hematomas, contusions usually are hypoechoic initially, becoming transiently

In a neonate with a decreasing hematocrit level and increasing abdominal distension,

isotope from the liver, increasing the target-to-background ratio of activity.

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Angiographic findings in patients with liver contusion include the following:

Angiographic findings in patients with liver lacerations include the following:

Arterial collaterals may bypass arterial occlusions.

Contrast material extravasation may occur.

Angiographic findings in patients with subcapsular hematoma include the following:

High-velocity bullet injuries

Low-velocity penetrating injuries (stab wounds, liver biopsy, and biliary

Arterial aneurysms and arterial pseudo-aneurysms

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