Management of hepatic trauma in adults

Authors:
Ashley Britton Christmas, MD, FACS
David G Jacobs, MD
Section Editor:
Eileen M Bulger, MD, FACS
Deputy Editor:
Kathryn A Collins, MD, PhD, FACS
All topics are updated as new evidence becomes available and our peer review process
is complete.
Literature review current through: Jan 2018. | This topic last updated: Dec 13, 2017.

INTRODUCTION — The liver is the most frequently injured abdominal organ. Most
hepatic injuries are relatively minor and heal spontaneously with nonoperative
management, which consists of observation and possibly arteriography and
embolization [1,2]. Operative intervention to manage the liver injury is needed in
approximately 14 percent of patients, including those who initially present with
hemodynamic instability or those who fail nonoperative management [2,3].

The diagnosis and management of hepatic injury in adults is reviewed here. Surgical
techniques to manage liver injury are discussed in detail elsewhere. (See "Surgical
techniques for managing hepatic injury".)

MECHANISM OF INJURY — The liver is the most commonly injured organ in blunt
abdominal trauma and the second most commonly injured organ in penetrating
abdominal trauma [3-6]. The liver is a highly vascular organ located in the right upper
quadrant (figure 1) of the abdomen and is susceptible to injury from traumatic
mechanisms. Among patients with blunt injury, motor vehicle collision is the most
common injury mechanism [3]. In patients with penetrating liver injury, the severity of
injury depends upon the trajectory of the missile or implement, and injuries can range
from simple parenchymal to major vascular laceration.

The liver margin, which can usually be palpated 2 to 3 cm below the right rib margin,
rises and falls with the diaphragm during respiration. The dome of the liver rises as high
as the level of T4 (nipple) with expiration. Thus, injuries to the chest wall are often
associated with significant injury to the liver. Similarly, the inferior margin of the liver
descends to as low as T12 with deep inspiration, and injuries, particularly penetrating
injuries, have the potential to injure the liver lower in the abdomen than might be
expected. The posterior portion of the right lobe (figure 2) is the most common site of
hepatic injury in blunt trauma [7].

TRAUMA EVALUATION — We perform the initial resuscitation, diagnostic

evaluation, and management of the trauma patient with blunt or penetrating trauma
based upon protocols from the Advanced Trauma Life Support (ATLS) program,
established by the American College of Surgeons Committee on Trauma. The initial
resuscitation and evaluation of the patient with blunt or penetrating abdominal or
thoracic trauma is discussed in detail elsewhere.

●(See "Initial evaluation and management of blunt abdominal trauma in adults".)

●(See "Initial evaluation and management of abdominal gunshot wounds in adults".)

●(See "Initial evaluation and management of abdominal stab wounds in adults".)

●(See "Initial evaluation and management of blunt thoracic trauma in adults".)

●(See "Initial evaluation and management of penetrating thoracic trauma in adults".)

Hemodynamically unstable trauma patients should be transferred immediately to the

operating room for evaluation and management. If the clinical setting allows, a Focused
Assessment with Sonography for Trauma (FAST) exam, diagnostic peritoneal lavage
(DPL), or computed tomography (CT) scan may be performed. The choice of test and
their value in the diagnostic evaluation of the trauma patient are discussed in detail
elsewhere.

●(See "Initial evaluation and management of blunt abdominal trauma in adults", section
on 'Ultrasound' and "Initial evaluation and management of abdominal gunshot wounds
in adults", section on 'Ultrasound' and "Initial evaluation and management of abdominal
stab wounds in adults", section on 'Ultrasound'.)

●(See "Initial evaluation and management of blunt abdominal trauma in adults", section
on 'Diagnostic peritoneal lavage (DPL)' and "Initial evaluation and management of
abdominal stab wounds in adults", section on 'Diagnostic peritoneal tap and diagnostic
peritoneal lavage' and "Initial evaluation and management of abdominal gunshot
wounds in adults", section on 'Diagnostic peritoneal lavage'.)

Plain films obtained during the trauma evaluation are generally nonspecific but may
demonstrate right-sided rib fractures, which increase the suspicion for liver injury.

Specific elements of the history, physical examination, and imaging evaluation that
pertain to liver injury are discussed below.

History and physical examination — A history of trauma to the right upper quadrant,
right rib cage, or right flank should increase the suspicion for liver injury. The patient
may complain of pain in the right upper abdomen, right chest wall, or right shoulder due
to diaphragmatic irritation.

Abdominal tenderness and peritoneal signs are the most common findings indicative of
intra-abdominal injury; however, these are not sensitive or specific for liver injury.
Physical findings associated with liver injury include right upper quadrant or
generalized abdominal tenderness, abdominal wall contusion or hematoma (eg, seatbelt
sign), right lower chest wall tenderness, contusion, or instability due to rib fractures.
Specific attention should be paid to any wounds that penetrate the right chest, abdomen,
flank, or back, remembering that significant liver damage can occur without a wound in
close proximity to it. A negative history and exam does not reliably exclude liver injury.

In the setting of injury, many patients have altered mental status (eg, neurologic injury,
intoxication) or are intubated and sedated and cannot relate their symptoms or medical
history. Any preexisting medical conditions should be identified, particularly those
requiring antiplatelet or anticoagulant therapy. (See "Overview of inpatient management
in the adult trauma patient", section on 'Patient assessment'.)

Associated injuries — Other injuries are present in approximately 80 percent of patients

with hepatic injury. In one series of 146 cases of hepatic injury, chest injury was the
most commonly associated injury overall, and the spleen was the most commonly
injured intra-abdominal organ [8]. Other injuries associated with a blunt mechanism
include lower rib fractures, pelvic fracture, and spinal cord injury.

Injuries associated with penetrating mechanisms depend upon the implement and
missile trajectory. Injuries to adjacent organs can occur in conjunction with liver
laceration and include injuries to the vena cava, extrahepatic portal structures, colon,
diaphragm, right lung, duodenum, and right kidney.

Laboratory studies — There are no specific laboratory tests diagnostic for hepatic
injury. An initially elevated white blood cell count in the trauma patient is common and
frequently related only to the physical stress of trauma. A finding of anemia is similarly
nonspecific. The degree of anemia is related to the volume of blood lost, which can be
from sites other than the liver, and the nature (crystalloid versus colloid) and volume of
fluid resuscitation. The time course for developing anemia following post-traumatic
hemorrhage is variable and related to the rapidity of exogenous fluid administration and
endogenous fluid shifts. Thus, the absence of anemia at the time of initial patient
presentation does not rule out significant liver trauma-related bleeding. Many studies
have investigated the predictive value of liver function studies in diagnosing liver
injury, but no consensus regarding their utility has been reached [9].

DIAGNOSIS — A diagnosis of liver injury may be suspected in the hemodynamically

stable patient based upon mechanism of injury, physical examination, or laboratory
findings. However, imaging using intravenous contrast-enhanced computed tomography
(CT) of the abdomen definitively confirms the injury and defines the injury grade.
Pooling of intravenous contrast in or around the liver implies ongoing bleeding and the
need for intervention [10,11]. CT scanning also identifies associated intra-abdominal
and chest injuries.

The Focused Assessment with Sonography in Trauma (FAST) exam is more commonly
used in hemodynamically unstable patients. However, a negative FAST examination is
not adequate to exclude liver injury, particularly intraparenchymal injury. On FAST
examination, signs of liver injury include findings of a hypoechoic (ie, black) rim of
subcapsular fluid, intraperitoneal fluid around the liver, or fluid in Morrison's pouch
(hepatorenal space). Although diagnostic peritoneal aspiration/lavage (DPA/DPL) has
largely been replaced by the FAST examination in most major trauma centers, it may
still be useful in selected patients, if the FAST is equivocal.

Organ-based ultrasound imaging and magnetic resonance imaging (MRI) are of limited
value in the initial diagnosis of liver injury. Organ-based ultrasound imaging and MRI
are time consuming to perform and may put the patient in a location remote from ready
access and intervention. However, MRI may be useful in a subset of hemodynamically
stable patients who cannot undergo CT scan (eg, allergic to intravenous [IV] contrast) or
have extrahepatic ductal injury. (See "Management of duodenal and pancreatic trauma
in adults", section on 'Magnetic resonance cholangiopancreatography' and "Magnetic
resonance cholangiopancreatography", section on 'Pancreatic duct disruption'.)

Arteriography is generally reserved for patients who have indications for hepatic
embolization to manage intrahepatic arterial hemorrhage. (See 'Hepatic embolization'
below.)

HEPATIC INJURY GRADING — We use the American Association for the Surgery of
Trauma (AAST) classification system, the most widely accepted injury grading scale, to
grade hepatic injuries [3,12]. Another hepatic injury grading system has been proposed
by the World Society of Emergency Surgery that reflects both the hemodynamic status
of the patient as well as the AAST anatomic grade of the injury [13,14].

The AAST grades of hepatic injury are as follows:

●Grade I – Hematoma: Subcapsular <10 percent surface area. Laceration: Capsular tear
<1 cm parenchymal depth (image 1).

●Grade II – Hematoma: Subcapsular 10 to 50 percent surface area (image 2);

intraparenchymal <10 cm in diameter (image 3). Laceration: Capsular tear 1 to 3 cm
parenchymal depth, <10 cm in length (image 4).

●Grade III – Hematoma: Subcapsular >50 percent of surface area or ruptured

subcapsular or parenchymal hematoma; intraparenchymal hematoma >10 cm or
expanding. Laceration >3 cm in depth (image 5).

●Grade IV – Laceration: Parenchymal disruption involving 25 to 75 percent of a hepatic

lobe (image 6 and image 7), or one to three Couinaud segments (figure 2).

●Grade V – Laceration: Parenchymal disruption of >75 percent of a hepatic lobe, >3

Couinaud segments (figure 2) within a single lobe. Vascular: Juxtahepatic venous
injuries (retrohepatic vena cava, central major hepatic veins) (image 8).

●Grade VI – Hepatic avulsion.

Most hepatic injuries are low grade. In a study of the solid organ injuries in the National
Trauma Data Bank (NTDB) in 2008, 67 percent of hepatic injuries were grade I, II, or
III [3]. The AAST grading system is useful for predicting the likelihood of success with
nonoperative management, which is higher for low-grade injuries (grade I, II, III)
compared with high-grade injuries (grade IV, V). Patients with grade VI injuries are
universally hemodynamically unstable, mandating surgical intervention.

APPROACH TO MANAGEMENT — Improved speed and sensitivity of diagnostic

imaging, most notably computed tomography (CT) scanning, accompanied by advances
in critical care monitoring, have promoted a shift from operative to nonoperative
management for most hemodynamically stable patients with hepatic injury. This
practice has been associated with a decline in morbidity and mortality [1,2,4,8,15-20].
(See 'Morbidity and mortality' below.)
The management strategy (operative or nonoperative) depends upon the hemodynamic
status of the patient, grade of liver injury, and presence of other injuries and medical
comorbidities.

●The hemodynamically unstable trauma patient with a positive Focused Assessment

with Sonography for Trauma (FAST) scan or positive diagnostic peritoneal lavage or
aspirate (DPA/DPL) requires emergent abdominal exploration to determine the source
of intraperitoneal hemorrhage. When the source of bleeding is the liver, exploratory
laparotomy is performed and control of bleeding may be through a damage-control
approach or by using specific techniques for liver hemostasis depending upon the
presence and extent of associated injuries and the extent of the liver injury. (See
"Overview of damage control surgery and resuscitation in patients sustaining severe
injury" and "Surgical techniques for managing hepatic injury", section on 'Techniques
for liver hemostasis'.)

●Patients with blunt liver injury who are hemodynamically stable and who do not have
other indications for abdominal exploration can be observed [1,2,4,5,8,15,20-26].
Hemodynamically stable patients with right-sided penetrating thoracoabdominal injuries
that lacerate the liver can also be observed, provided there are no associated intra-
abdominal injuries. Patients with higher-grade injuries fail nonoperative management
more commonly than those with lower-grade injuries, but these patients should still be
offered nonoperative management so long as they remain hemodynamically stable. In
general, patients who meet the criteria for the observation of liver injury but who
require intervention to treat extra-abdominal injuries (eg, leg fracture stabilization) can
also be observed. (See 'Nonoperative management' below.)

Surgical exploration is indicated in nonoperatively managed patients who continue to

bleed (ongoing blood transfusion, hemodynamic instability), and in some patients who
manifest a persistent systemic inflammatory response (ileus, fever, tachycardia,
oliguria). The management of grade III injuries and higher often requires a combined
angiographic and surgical approach. Rarely, total hepatectomy and immediate
posthepatectomy transplantation may be needed. (See 'Hepatic embolization' below and
"Surgical techniques for managing hepatic injury".)

NONOPERATIVE MANAGEMENT — Nonoperative management is the treatment of

choice for hemodynamically stable patients with hepatic injury, regardless of injury
grade, and consists of observation and supportive care with the adjunctive use of
arteriography and hepatic embolization [27]. Retrospective reviews of the National
Trauma Data Bank and other observational studies have found that more than 80
percent of patients with blunt hepatic injury can be treated nonoperatively with success
rates (defined as no need for operative intervention for the hepatic injury) in >90
percent of patients [1,5,19,21,26,28-32]. A review of the National Trauma Data Bank
identified 35,510 hepatic injuries over a 10-year period from 1994 to 2003 [5]. Of these,
91 percent of adults were successfully managed nonoperatively. Over the study period,
the percentage of patients with liver injury managed nonoperatively rose from 75 to 82
percent, but the overall mortality associated with liver trauma remained unchanged at
approximately 15 percent. The steady improvement in rates of successful nonoperative
management that has occurred in the United States since the mid-1990s appears to be
associated with greater overall survival, reduced resource consumption, and lower
health care expenditures for patients with liver injuries [25]. Greater utilization of
damage control resuscitation strategies over this time period appears to be one factor
leading to these higher successful nonoperative management rates [33].

Successful nonoperative management requires appropriate patient selection and the

availability of resources, including availability of intensive care unit beds, blood bank
support, immediate operating room availability, and surgeons and interventional
angiographers experienced in managing hepatic injury.

Patients who are hemodynamically stable but demonstrate extravasation from the liver
on computed tomography (CT) of the abdomen have higher failure rates with
nonoperative management, and these patients should undergo arteriography and
possible liver embolization followed by continued observation and serial hemoglobin
determination. (See 'Hepatic embolization' below.)

Contraindications to nonoperative management — Contraindications to nonoperative

management of liver injury include the following [1,34,35]:

●Hemodynamic instability after initial resuscitation.

●Other indication for abdominal surgery (eg, peritonitis).

●Gunshot injury (relative contraindication if extrahepatic injury is suspected).

●Absence of an appropriate clinical environment to provide monitoring, serial clinical

evaluation, or availability of facilities and personnel for hepatic embolization or urgent
abdominal exploration should the need arise.

Nonoperative management of gunshot wounds remains controversial even though

nonoperative management of patients with isolated penetrating hepatic injuries due to
abdominal stab wounds has been practiced routinely at many trauma centers for several
years [36]. Nonoperative management of these patients fails in up to one-third of
patients due to ongoing bleeding, or the development of abdominal compartment
syndrome [18,23,35,37]. Missed injuries to the gastrointestinal tract are also a concern.

Observation — Nonoperatively managed patients should be admitted to a monitored

unit and initially placed on bed rest [1]. Patients must be closely monitored by nursing
and medical staff, and sufficient flexibility should be available to allow urgent/emergent
intervention (arteriography or surgery). (See 'Failure of nonoperative management'
below.)

Large observational studies support the practice of discharging patients with liver injury
who are being observed to home provided they have a normal abdominal examination
and stable hemoglobin for at least 24 hours, regardless of the grade of injury. The length
of observation is based solely on clinical criteria [38,39].

Patients with liver injury or other severe injuries who require hospitalization are at a
high risk for thromboembolism and should receive thromboprophylaxis; however,
chemical thromboprophylaxis may need to be delayed due to an increased risk of
bleeding (eg, cerebral injury). Provided there are no other contraindications to
pharmacologic prophylaxis, we typically initiate treatment when the hemoglobin has
stabilized with less than 1 g hemoglobin decrement over a 24-hour period of time.
Pharmacologic prophylaxis does not appear to increase nonoperative management
failure rates or blood transfusion requirements [40,41]. (See "Overview of inpatient
management in the adult trauma patient", section on 'Thromboprophylaxis'.)

Hepatic embolization — Hepatic embolization may be necessary as an adjunct to

improve rates of nonoperative management. Hepatic embolization requires special
imaging facilities and a vascular interventionalist (ie, interventional radiology, vascular
surgeon) experienced with celiac artery catheterization and embolization techniques.
The overall efficacy of angioembolization in hepatic trauma is 93 percent [42]. Success
rates for embolization vary depending upon institution, embolization technique, arterial
accessibility, operator skill, and the type of embolization material used. In some centers,
hepatic embolization has replaced the need for initial operative intervention [16,34,43-
45].

Hepatic embolization appears to be most successful when used preemptively in

hemodynamically stable patients who demonstrate extravasation of contrast on the
initial abdominal CT scan. However, occasionally angiography fails to show a discrete
bleeding site in spite of evidence of contrast extravasation on the initial abdominal CT
scan. Under these circumstances, empiric embolization can be performed to reduce the
risk of recurrent hemorrhage that is seen when embolization is not performed under this
circumstance [46].

Hepatic embolization can also be used to treat patients who have failed observational
management [16,47,48], or adjunctively to manage patients with ongoing bleeding or
rebleeding from the liver after surgical management (algorithm 1) [47]. In one
systematic review of severe liver injuries (grade III/IV), overall, 1 to 5 percent of
patients treated nonoperatively required embolization for recurrent bleeding more than
24 hours after admission, while 12 to 28 percent of those requiring laparotomy for
hemodynamic instability required secondary embolization to control recurrent
postoperative bleeding [31].

Depending upon the nature of the injury and technical factors, embolization coils,
microspheres, absorbable gelatin sponge, or endogenous clot can be used to interrupt
blood flow in the main hepatic artery or branch vessels. Ischemic complications related
to angioembolization are not uncommon and may lead to a need for surgical
debridement or liver resection [42,49,50]. (See 'Morbidity and mortality' below.)

Benefits and risks of nonoperative management — When nonoperative management is

successful, the risks inherent to surgery and anesthesia are eliminated. However,
disadvantages associated with nonoperative management include an increased risk of
missed intra-abdominal injury, particularly hollow viscus injury, transfusion-related
illness, and risks associated with embolization techniques, which include hepatic
necrosis, abscess formation, and bile leaks [42]. (See 'Morbidity and mortality' below.)

Patients with missed gastrointestinal hollow viscus injury present with worsening
abdominal pain and peritoneal signs, generally by postinjury day 4. These patients
require operative intervention, and, during exploration, the liver injury should also be
evaluated. (See "Traumatic gastrointestinal injury in the adult patient" and "Surgical
techniques for managing hepatic injury".)
Blood transfusion is associated with many complications that can include intravascular
volume overload (transfusion-associated circulatory overload [TACO]), transfusion-
related acute lung injury (TRALI), hypothermia, coagulopathy, and immunologic and
allergic reactions, as well as immunomodulation (transfusion-related immune
modulation [TRIM]). Some clinicians feel these risks may outweigh the benefits of
aggressive nonoperative management strategies, particularly in patients with high-grade
liver injuries. The risks associated with blood transfusion are discussed in detail
elsewhere. (See "Use of blood products in the critically ill", section on 'Complications'
and "Transfusion-related acute lung injury (TRALI)" and "Leukoreduction to prevent
complications of blood transfusion", section on 'Immunosuppression' and "Transfusion-
associated circulatory overload (TACO)".)

Hepatic embolization is associated with additional risks that include bleeding, arterial
access site complications, hepatic necrosis, liver/subdiaphragmatic abscess, inadvertent
embolization of other organs (eg, bowel, pancreas) or lower extremities, allergic
reaction to contrast, and contrast-induced nephropathy. The risk of contrast-induced
nephropathy may be greater when embolization is performed following contrast CT
scan, particularly in patients who may already be volume depleted. Contrast-induced
nephropathy and its prevention are discussed in detail elsewhere. (See "Pathogenesis,
clinical features, and diagnosis of contrast-induced nephropathy" and "Prevention of
contrast nephropathy associated with angiography".)

Failure of nonoperative management — Failure of nonoperative management

(observation and/or embolization) is defined as the need for operative intervention and
is generally related to bleeding that becomes apparent by the need for ongoing fluid
resuscitation or transfusion, or hemodynamic instability. Other factors (other than blood
pressure, fluid resuscitation, blood transfusion) identified in a systematic review that
were associated with failure of nonoperative management included peritoneal signs,
Injury Severity Score (ISS), and associated intra-abdominal injuries [51].

Patients who become hemodynamically unstable, by definition, have failed

nonoperative management and should be taken immediately to the operating room for
abdominal exploration. Arteriography with embolization should not be pursued under
these circumstances given the time needed to set up the interventional radiology suite,
get personnel in place, and perform the embolization procedure.

Hypotension may be absolute or relative, or manifested as persistent tachycardia despite

adequate fluid resuscitation. A study using data from the National Trauma Data Bank
(NTDB) identified a trend toward increasing attempts at nonoperative management for
severe liver injuries [32]. Although failure rates for nonoperative management of
hepatic injury are generally low (approximately 7 percent), failed nonoperative
management is associated with an increased mortality [10,37,44,52,53].

In a retrospective review of 591 patients managed nonoperatively for blunt liver injury,
6 percent failed nonoperative management, with approximately one-half of these due to
ongoing bleeding from other injuries [43]. Patients with grade IV or V injuries are more
likely to fail nonoperative management. In one study, logistic regression found that
blood transfusion ≥3 units (odds ratio 10.8, 95% CI 1.6-72.2) was an independent risk
factor for surgical intervention [52]. Most protocols allow for continued observation
with up to 4 units of blood transfusion related to the hepatic injury.
Follow-up care — There are few data to guide the routine care and follow-up of patients
with hepatic injury who have been managed nonoperatively. No definitive
recommendations have been established regarding the need or timing of follow-up
imaging, the need for or duration of bed rest, the timing of return to daily activities
and/or exercise, or the timing to initiate prophylactic or therapeutic anticoagulation
[6,54]. Although it is a common recommendation that patients avoid strenuous activities
for several weeks, this remains intuitive with few data to support this practice [35]. For
patients with higher-grade injuries, we restrict strenuous physical activity for a longer
period of time, which, for grade V injury, can be as long as three months.

SURGICAL MANAGEMENT — The operative management of liver injuries that

require surgical intervention can be a challenge even for experienced surgeons due to
the complex nature of the liver, its size, vascularity, dual blood supply (portal, hepatic
arterial), and its rich and difficult-to-access venous drainage. In hemodynamically
unstable patients, damage control techniques provide temporary control of bleeding and
allow anesthesia staff to resuscitate the patient. Definitive management of bleeding from
the liver is accomplished using a variety of techniques. The surgical management of
hepatic injury is discussed in detail elsewhere. (See "Surgical techniques for managing
hepatic injury".)

MORBIDITY AND MORTALITY — Mortality rates for hepatic injury vary according
to the grade of the injury and have improved over time with the introduction of
nonoperative management strategies and the use of perihepatic packing [17]. Since
mortality is unusual with grade I and II injuries, the greatest reduction in operative
mortality has occurred for higher-grade liver injuries (grade III, IV, V) [24,25,48,55-
58]. Many of these higher-grade injuries can be successfully managed nonoperatively
with overall low mortality rates ranging from 0 to 8 percent. Higher mortality rates are
seen for those patients with high-grade injuries who require surgical management either
immediately or as a result of failed nonoperative management (30 to 68 percent) [31].
Many studies do not include mortality rates related to juxtahepatic injury, for which
mortality rates remain extremely high (77 percent in one series) [26].

Complications are common following the management of liver injuries. The incidence
of complications increases with the grade of liver injury [23,59]. In a series of 669
patients, complications developed in 5, 22, and 52 percent of patients with grade III, IV,
and V injuries, respectively [56]. Complications associated with lower-grade injuries
(grade I, II) are rare.

Biliary tree disruption with formation of biloma and/or persistent bile leak is a frequent
complication of nonoperative management for liver injury. The incidence of bile leak
ranges from 0.5 to 21 percent [44,60-62]. Bile leak manifests as abdominal pain or a
persistent systemic inflammatory response syndrome (SIRS) with fever, tachycardia,
and leukocytosis. Repeat abdominal computed tomography (CT) scan establishes the
diagnosis. Biliary tree disruption with persistent bilious drainage can often be
successfully managed by endoscopic retrograde cholangiopancreatography and stent
placement. However, findings on abdominal CT consistent with bile ascites and/or
persistent hemoperitoneum warrant laparoscopic evaluation with abdominal irrigation
and drainage to remove the bile, which is very irritating to the peritoneum. Findings
consistent with perihepatic abscesses can usually be managed with antibiotics and
percutaneous drainage techniques, but surgery may be needed if interventional
techniques fail to provide adequate drainage [59].

Hepatic necrosis to some extent commonly occurs following angioembolization for

hepatic injury but may also be seen following laparotomy and hepatorrhaphy [48,50].
The combination of hepatic injury and ischemia induced by embolization may
predispose to major hepatic necrosis, particularly in patients who have previously
undergone surgery [50]. Major hepatic necrosis is managed surgically with repeated
resectional debridement in conjunction with interventional drainage procedures, or
hepatic lobectomy [49,50]. Early lobectomy rather than repeated debridement may be
associated with a lower overall complication rate and the need for fewer procedures.
(See "Surgical techniques for managing hepatic injury", section on 'Liver resection'.)

SUMMARY AND RECOMMENDATIONS

●Hepatic injury can result from blunt or penetrating chest or abdominal trauma.
Following blunt trauma, the liver is the most commonly injured organ. Penetrating
injury to the liver is frequently associated with injuries to adjacent structures that can be
associated with mortality rates exceeding 75 percent in some studies. (See 'Introduction'
above and 'Associated injuries' above.)

●We perform initial resuscitation, diagnostic evaluation, and management of the trauma
patient based upon protocols from the Advanced Trauma Life Support (ATLS) program
developed by the American College of Surgeons Committee on Trauma.
Hemodynamically unstable patients with a positive Focused Assessment with
Sonography for Trauma (FAST) exam or diagnostic peritoneal lavage or aspirate
(DPL/DPA) require operative surgical exploration to determine the source of life-
threatening hemorrhage, which may be due to liver injury. (See 'Trauma evaluation'
above and 'Approach to management' above.)

●A suspicion of hepatic injury is increased with right upper quadrant and/or right chest
trauma; however, the clinical history and physical examination are not sufficiently
sensitive or specific for the presence of liver injury. (See "Management of splenic injury
in the adult trauma patient", section on 'Trauma evaluation' and 'Trauma evaluation'
above.)

●Computed tomography (CT) of the abdomen identifies the presence of liver injury and
defines its severity in hemodynamically stable patients. Hepatic injury is graded (I
through VI) depending upon the extent and depth of liver hematoma and/or laceration as
identified on abdominal CT, or at the time of surgery. Higher grades of hepatic injury
correlate with increasing morbidity and mortality. (See 'Hepatic injury grading' above
and 'Morbidity and mortality' above.)

●For hemodynamically stable patients with liver injury with no other indication for
abdominal exploration, we suggest nonoperative management over definitive surgical
intervention, regardless of hepatic injury grade (Grade 2C). Observation involves
monitored care, serial abdominal examination, and serial hemoglobin assessment and
potentially hepatic embolization. Failure of nonoperative management (ongoing
transfusion, hemodynamic instability) indicates the need for hepatic embolization or
surgery. (See 'Nonoperative management' above.)
●For hemodynamically stable patients with liver injury who demonstrate pooling of
intravenous contrast on initial or subsequent abdominal CT scan, we suggest hepatic
embolization rather than nonoperative management without embolization (Grade 2C).
Hepatic embolization requires specialized imaging facilities and an appropriately
trained interventionalist experienced with celiac artery catheterization. Failure of
hepatic embolization to control bleeding indicates the need for surgery. (See 'Hepatic
embolization' above and "Surgical techniques for managing hepatic injury".)

●Mortality has decreased with the introduction of nonoperative management strategies

and damage control techniques. Mortality for low-grade (I, II, III) injuries is rare but
ranges from 10 to 42 percent for high-grade injuries (IV, V, VI). Complications related
to nonoperative management are common and include bile leak that can lead to ascites,
biloma, or abscess, and hepatic necrosis related to angioembolization. (See 'Morbidity
and mortality' above.)

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Management of hepatic trauma in adults
Authors:
Ashley Britton Christmas, MD, FACS
David G Jacobs, MD
Section Editor:
Eileen M Bulger, MD, FACS
Deputy Editor:
Kathryn A Collins, MD, PhD, FACS
All topics are updated as new evidence becomes available and our peer review process
is complete.
Literature review current through: Jan 2018. | This topic last updated: Dec 13, 2017.

INTRODUCTION — The liver is the most frequently injured abdominal organ. Most
hepatic injuries are relatively minor and heal spontaneously with nonoperative
management, which consists of observation and possibly arteriography and
embolization [1,2]. Operative intervention to manage the liver injury is needed in
approximately 14 percent of patients, including those who initially present with
hemodynamic instability or those who fail nonoperative management [2,3].

The diagnosis and management of hepatic injury in adults is reviewed here. Surgical
techniques to manage liver injury are discussed in detail elsewhere. (See "Surgical
techniques for managing hepatic injury".)

MECHANISM OF INJURY — The liver is the most commonly injured organ in blunt
abdominal trauma and the second most commonly injured organ in penetrating
abdominal trauma [3-6]. The liver is a highly vascular organ located in the right upper
quadrant (figure 1) of the abdomen and is susceptible to injury from traumatic
mechanisms. Among patients with blunt injury, motor vehicle collision is the most
common injury mechanism [3]. In patients with penetrating liver injury, the severity of
injury depends upon the trajectory of the missile or implement, and injuries can range
from simple parenchymal to major vascular laceration.

The liver margin, which can usually be palpated 2 to 3 cm below the right rib margin,
rises and falls with the diaphragm during respiration. The dome of the liver rises as high
as the level of T4 (nipple) with expiration. Thus, injuries to the chest wall are often
associated with significant injury to the liver. Similarly, the inferior margin of the liver
descends to as low as T12 with deep inspiration, and injuries, particularly penetrating
injuries, have the potential to injure the liver lower in the abdomen than might be
expected. The posterior portion of the right lobe (figure 2) is the most common site of
hepatic injury in blunt trauma [7].

TRAUMA EVALUATION — We perform the initial resuscitation, diagnostic

evaluation, and management of the trauma patient with blunt or penetrating trauma
based upon protocols from the Advanced Trauma Life Support (ATLS) program,
established by the American College of Surgeons Committee on Trauma. The initial
resuscitation and evaluation of the patient with blunt or penetrating abdominal or
thoracic trauma is discussed in detail elsewhere.

●(See "Initial evaluation and management of blunt abdominal trauma in adults".)

●(See "Initial evaluation and management of abdominal gunshot wounds in adults".)

●(See "Initial evaluation and management of abdominal stab wounds in adults".)

●(See "Initial evaluation and management of blunt thoracic trauma in adults".)

●(See "Initial evaluation and management of penetrating thoracic trauma in adults".)

Hemodynamically unstable trauma patients should be transferred immediately to the

operating room for evaluation and management. If the clinical setting allows, a Focused
Assessment with Sonography for Trauma (FAST) exam, diagnostic peritoneal lavage
(DPL), or computed tomography (CT) scan may be performed. The choice of test and
their value in the diagnostic evaluation of the trauma patient are discussed in detail
elsewhere.

●(See "Initial evaluation and management of blunt abdominal trauma in adults", section
on 'Ultrasound' and "Initial evaluation and management of abdominal gunshot wounds
in adults", section on 'Ultrasound' and "Initial evaluation and management of abdominal
stab wounds in adults", section on 'Ultrasound'.)

●(See "Initial evaluation and management of blunt abdominal trauma in adults", section
on 'Diagnostic peritoneal lavage (DPL)' and "Initial evaluation and management of
abdominal stab wounds in adults", section on 'Diagnostic peritoneal tap and diagnostic
peritoneal lavage' and "Initial evaluation and management of abdominal gunshot
wounds in adults", section on 'Diagnostic peritoneal lavage'.)

Plain films obtained during the trauma evaluation are generally nonspecific but may
demonstrate right-sided rib fractures, which increase the suspicion for liver injury.

Specific elements of the history, physical examination, and imaging evaluation that
pertain to liver injury are discussed below.

History and physical examination — A history of trauma to the right upper quadrant,
right rib cage, or right flank should increase the suspicion for liver injury. The patient
may complain of pain in the right upper abdomen, right chest wall, or right shoulder due
to diaphragmatic irritation.

Abdominal tenderness and peritoneal signs are the most common findings indicative of
intra-abdominal injury; however, these are not sensitive or specific for liver injury.
Physical findings associated with liver injury include right upper quadrant or
generalized abdominal tenderness, abdominal wall contusion or hematoma (eg, seatbelt
sign), right lower chest wall tenderness, contusion, or instability due to rib fractures.
Specific attention should be paid to any wounds that penetrate the right chest, abdomen,
flank, or back, remembering that significant liver damage can occur without a wound in
close proximity to it. A negative history and exam does not reliably exclude liver injury.

In the setting of injury, many patients have altered mental status (eg, neurologic injury,
intoxication) or are intubated and sedated and cannot relate their symptoms or medical
history. Any preexisting medical conditions should be identified, particularly those
requiring antiplatelet or anticoagulant therapy. (See "Overview of inpatient management
in the adult trauma patient", section on 'Patient assessment'.)

Associated injuries — Other injuries are present in approximately 80 percent of patients

with hepatic injury. In one series of 146 cases of hepatic injury, chest injury was the
most commonly associated injury overall, and the spleen was the most commonly
injured intra-abdominal organ [8]. Other injuries associated with a blunt mechanism
include lower rib fractures, pelvic fracture, and spinal cord injury.

Injuries associated with penetrating mechanisms depend upon the implement and
missile trajectory. Injuries to adjacent organs can occur in conjunction with liver
laceration and include injuries to the vena cava, extrahepatic portal structures, colon,
diaphragm, right lung, duodenum, and right kidney.

Laboratory studies — There are no specific laboratory tests diagnostic for hepatic
injury. An initially elevated white blood cell count in the trauma patient is common and
frequently related only to the physical stress of trauma. A finding of anemia is similarly
nonspecific. The degree of anemia is related to the volume of blood lost, which can be
from sites other than the liver, and the nature (crystalloid versus colloid) and volume of
fluid resuscitation. The time course for developing anemia following post-traumatic
hemorrhage is variable and related to the rapidity of exogenous fluid administration and
endogenous fluid shifts. Thus, the absence of anemia at the time of initial patient
presentation does not rule out significant liver trauma-related bleeding. Many studies
have investigated the predictive value of liver function studies in diagnosing liver
injury, but no consensus regarding their utility has been reached [9].

DIAGNOSIS — A diagnosis of liver injury may be suspected in the hemodynamically

stable patient based upon mechanism of injury, physical examination, or laboratory
findings. However, imaging using intravenous contrast-enhanced computed tomography
(CT) of the abdomen definitively confirms the injury and defines the injury grade.
Pooling of intravenous contrast in or around the liver implies ongoing bleeding and the
need for intervention [10,11]. CT scanning also identifies associated intra-abdominal
and chest injuries.
The Focused Assessment with Sonography in Trauma (FAST) exam is more commonly
used in hemodynamically unstable patients. However, a negative FAST examination is
not adequate to exclude liver injury, particularly intraparenchymal injury. On FAST
examination, signs of liver injury include findings of a hypoechoic (ie, black) rim of
subcapsular fluid, intraperitoneal fluid around the liver, or fluid in Morrison's pouch
(hepatorenal space). Although diagnostic peritoneal aspiration/lavage (DPA/DPL) has
largely been replaced by the FAST examination in most major trauma centers, it may
still be useful in selected patients, if the FAST is equivocal.

Organ-based ultrasound imaging and magnetic resonance imaging (MRI) are of limited
value in the initial diagnosis of liver injury. Organ-based ultrasound imaging and MRI
are time consuming to perform and may put the patient in a location remote from ready
access and intervention. However, MRI may be useful in a subset of hemodynamically
stable patients who cannot undergo CT scan (eg, allergic to intravenous [IV] contrast) or
have extrahepatic ductal injury. (See "Management of duodenal and pancreatic trauma
in adults", section on 'Magnetic resonance cholangiopancreatography' and "Magnetic
resonance cholangiopancreatography", section on 'Pancreatic duct disruption'.)

Arteriography is generally reserved for patients who have indications for hepatic
embolization to manage intrahepatic arterial hemorrhage. (See 'Hepatic embolization'
below.)

HEPATIC INJURY GRADING — We use the American Association for the Surgery of
Trauma (AAST) classification system, the most widely accepted injury grading scale, to
grade hepatic injuries [3,12]. Another hepatic injury grading system has been proposed
by the World Society of Emergency Surgery that reflects both the hemodynamic status
of the patient as well as the AAST anatomic grade of the injury [13,14].

The AAST grades of hepatic injury are as follows:

●Grade I – Hematoma: Subcapsular <10 percent surface area. Laceration: Capsular tear
<1 cm parenchymal depth (image 1).

●Grade II – Hematoma: Subcapsular 10 to 50 percent surface area (image 2);

intraparenchymal <10 cm in diameter (image 3). Laceration: Capsular tear 1 to 3 cm
parenchymal depth, <10 cm in length (image 4).

●Grade III – Hematoma: Subcapsular >50 percent of surface area or ruptured

subcapsular or parenchymal hematoma; intraparenchymal hematoma >10 cm or
expanding. Laceration >3 cm in depth (image 5).

●Grade IV – Laceration: Parenchymal disruption involving 25 to 75 percent of a hepatic

lobe (image 6 and image 7), or one to three Couinaud segments (figure 2).

●Grade V – Laceration: Parenchymal disruption of >75 percent of a hepatic lobe, >3

Couinaud segments (figure 2) within a single lobe. Vascular: Juxtahepatic venous
injuries (retrohepatic vena cava, central major hepatic veins) (image 8).

●Grade VI – Hepatic avulsion.

Most hepatic injuries are low grade. In a study of the solid organ injuries in the National
Trauma Data Bank (NTDB) in 2008, 67 percent of hepatic injuries were grade I, II, or
III [3]. The AAST grading system is useful for predicting the likelihood of success with
nonoperative management, which is higher for low-grade injuries (grade I, II, III)
compared with high-grade injuries (grade IV, V). Patients with grade VI injuries are
universally hemodynamically unstable, mandating surgical intervention.

APPROACH TO MANAGEMENT — Improved speed and sensitivity of diagnostic

imaging, most notably computed tomography (CT) scanning, accompanied by advances
in critical care monitoring, have promoted a shift from operative to nonoperative
management for most hemodynamically stable patients with hepatic injury. This
practice has been associated with a decline in morbidity and mortality [1,2,4,8,15-20].
(See 'Morbidity and mortality' below.)

The management strategy (operative or nonoperative) depends upon the hemodynamic

status of the patient, grade of liver injury, and presence of other injuries and medical
comorbidities.

●The hemodynamically unstable trauma patient with a positive Focused Assessment

with Sonography for Trauma (FAST) scan or positive diagnostic peritoneal lavage or
aspirate (DPA/DPL) requires emergent abdominal exploration to determine the source
of intraperitoneal hemorrhage. When the source of bleeding is the liver, exploratory
laparotomy is performed and control of bleeding may be through a damage-control
approach or by using specific techniques for liver hemostasis depending upon the
presence and extent of associated injuries and the extent of the liver injury. (See
"Overview of damage control surgery and resuscitation in patients sustaining severe
injury" and "Surgical techniques for managing hepatic injury", section on 'Techniques
for liver hemostasis'.)

●Patients with blunt liver injury who are hemodynamically stable and who do not have
other indications for abdominal exploration can be observed [1,2,4,5,8,15,20-26].
Hemodynamically stable patients with right-sided penetrating thoracoabdominal injuries
that lacerate the liver can also be observed, provided there are no associated intra-
abdominal injuries. Patients with higher-grade injuries fail nonoperative management
more commonly than those with lower-grade injuries, but these patients should still be
offered nonoperative management so long as they remain hemodynamically stable. In
general, patients who meet the criteria for the observation of liver injury but who
require intervention to treat extra-abdominal injuries (eg, leg fracture stabilization) can
also be observed. (See 'Nonoperative management' below.)

Surgical exploration is indicated in nonoperatively managed patients who continue to

bleed (ongoing blood transfusion, hemodynamic instability), and in some patients who
manifest a persistent systemic inflammatory response (ileus, fever, tachycardia,
oliguria). The management of grade III injuries and higher often requires a combined
angiographic and surgical approach. Rarely, total hepatectomy and immediate
posthepatectomy transplantation may be needed. (See 'Hepatic embolization' below and
"Surgical techniques for managing hepatic injury".)

NONOPERATIVE MANAGEMENT — Nonoperative management is the treatment of

choice for hemodynamically stable patients with hepatic injury, regardless of injury
grade, and consists of observation and supportive care with the adjunctive use of
arteriography and hepatic embolization [27]. Retrospective reviews of the National
Trauma Data Bank and other observational studies have found that more than 80
percent of patients with blunt hepatic injury can be treated nonoperatively with success
rates (defined as no need for operative intervention for the hepatic injury) in >90
percent of patients [1,5,19,21,26,28-32]. A review of the National Trauma Data Bank
identified 35,510 hepatic injuries over a 10-year period from 1994 to 2003 [5]. Of these,
91 percent of adults were successfully managed nonoperatively. Over the study period,
the percentage of patients with liver injury managed nonoperatively rose from 75 to 82
percent, but the overall mortality associated with liver trauma remained unchanged at
approximately 15 percent. The steady improvement in rates of successful nonoperative
management that has occurred in the United States since the mid-1990s appears to be
associated with greater overall survival, reduced resource consumption, and lower
health care expenditures for patients with liver injuries [25]. Greater utilization of
damage control resuscitation strategies over this time period appears to be one factor
leading to these higher successful nonoperative management rates [33].

Successful nonoperative management requires appropriate patient selection and the

availability of resources, including availability of intensive care unit beds, blood bank
support, immediate operating room availability, and surgeons and interventional
angiographers experienced in managing hepatic injury.

Patients who are hemodynamically stable but demonstrate extravasation from the liver
on computed tomography (CT) of the abdomen have higher failure rates with
nonoperative management, and these patients should undergo arteriography and
possible liver embolization followed by continued observation and serial hemoglobin
determination. (See 'Hepatic embolization' below.)

Contraindications to nonoperative management — Contraindications to nonoperative

management of liver injury include the following [1,34,35]:

●Hemodynamic instability after initial resuscitation.

●Other indication for abdominal surgery (eg, peritonitis).

●Gunshot injury (relative contraindication if extrahepatic injury is suspected).

●Absence of an appropriate clinical environment to provide monitoring, serial clinical

evaluation, or availability of facilities and personnel for hepatic embolization or urgent
abdominal exploration should the need arise.

Nonoperative management of gunshot wounds remains controversial even though

nonoperative management of patients with isolated penetrating hepatic injuries due to
abdominal stab wounds has been practiced routinely at many trauma centers for several
years [36]. Nonoperative management of these patients fails in up to one-third of
patients due to ongoing bleeding, or the development of abdominal compartment
syndrome [18,23,35,37]. Missed injuries to the gastrointestinal tract are also a concern.

Observation — Nonoperatively managed patients should be admitted to a monitored

unit and initially placed on bed rest [1]. Patients must be closely monitored by nursing
and medical staff, and sufficient flexibility should be available to allow urgent/emergent
intervention (arteriography or surgery). (See 'Failure of nonoperative management'
below.)

Large observational studies support the practice of discharging patients with liver injury
who are being observed to home provided they have a normal abdominal examination
and stable hemoglobin for at least 24 hours, regardless of the grade of injury. The length
of observation is based solely on clinical criteria [38,39].

Patients with liver injury or other severe injuries who require hospitalization are at a
high risk for thromboembolism and should receive thromboprophylaxis; however,
chemical thromboprophylaxis may need to be delayed due to an increased risk of
bleeding (eg, cerebral injury). Provided there are no other contraindications to
pharmacologic prophylaxis, we typically initiate treatment when the hemoglobin has
stabilized with less than 1 g hemoglobin decrement over a 24-hour period of time.
Pharmacologic prophylaxis does not appear to increase nonoperative management
failure rates or blood transfusion requirements [40,41]. (See "Overview of inpatient
management in the adult trauma patient", section on 'Thromboprophylaxis'.)

Hepatic embolization — Hepatic embolization may be necessary as an adjunct to

improve rates of nonoperative management. Hepatic embolization requires special
imaging facilities and a vascular interventionalist (ie, interventional radiology, vascular
surgeon) experienced with celiac artery catheterization and embolization techniques.
The overall efficacy of angioembolization in hepatic trauma is 93 percent [42]. Success
rates for embolization vary depending upon institution, embolization technique, arterial
accessibility, operator skill, and the type of embolization material used. In some centers,
hepatic embolization has replaced the need for initial operative intervention [16,34,43-
45].

Hepatic embolization appears to be most successful when used preemptively in

hemodynamically stable patients who demonstrate extravasation of contrast on the
initial abdominal CT scan. However, occasionally angiography fails to show a discrete
bleeding site in spite of evidence of contrast extravasation on the initial abdominal CT
scan. Under these circumstances, empiric embolization can be performed to reduce the
risk of recurrent hemorrhage that is seen when embolization is not performed under this
circumstance [46].

Hepatic embolization can also be used to treat patients who have failed observational
management [16,47,48], or adjunctively to manage patients with ongoing bleeding or
rebleeding from the liver after surgical management (algorithm 1) [47]. In one
systematic review of severe liver injuries (grade III/IV), overall, 1 to 5 percent of
patients treated nonoperatively required embolization for recurrent bleeding more than
24 hours after admission, while 12 to 28 percent of those requiring laparotomy for
hemodynamic instability required secondary embolization to control recurrent
postoperative bleeding [31].

Depending upon the nature of the injury and technical factors, embolization coils,
microspheres, absorbable gelatin sponge, or endogenous clot can be used to interrupt
blood flow in the main hepatic artery or branch vessels. Ischemic complications related
to angioembolization are not uncommon and may lead to a need for surgical
debridement or liver resection [42,49,50]. (See 'Morbidity and mortality' below.)

Benefits and risks of nonoperative management — When nonoperative management is

successful, the risks inherent to surgery and anesthesia are eliminated. However,
disadvantages associated with nonoperative management include an increased risk of
missed intra-abdominal injury, particularly hollow viscus injury, transfusion-related
illness, and risks associated with embolization techniques, which include hepatic
necrosis, abscess formation, and bile leaks [42]. (See 'Morbidity and mortality' below.)

Patients with missed gastrointestinal hollow viscus injury present with worsening
abdominal pain and peritoneal signs, generally by postinjury day 4. These patients
require operative intervention, and, during exploration, the liver injury should also be
evaluated. (See "Traumatic gastrointestinal injury in the adult patient" and "Surgical
techniques for managing hepatic injury".)

Blood transfusion is associated with many complications that can include intravascular
volume overload (transfusion-associated circulatory overload [TACO]), transfusion-
related acute lung injury (TRALI), hypothermia, coagulopathy, and immunologic and
allergic reactions, as well as immunomodulation (transfusion-related immune
modulation [TRIM]). Some clinicians feel these risks may outweigh the benefits of
aggressive nonoperative management strategies, particularly in patients with high-grade
liver injuries. The risks associated with blood transfusion are discussed in detail
elsewhere. (See "Use of blood products in the critically ill", section on 'Complications'
and "Transfusion-related acute lung injury (TRALI)" and "Leukoreduction to prevent
complications of blood transfusion", section on 'Immunosuppression' and "Transfusion-
associated circulatory overload (TACO)".)

Hepatic embolization is associated with additional risks that include bleeding, arterial
access site complications, hepatic necrosis, liver/subdiaphragmatic abscess, inadvertent
embolization of other organs (eg, bowel, pancreas) or lower extremities, allergic
reaction to contrast, and contrast-induced nephropathy. The risk of contrast-induced
nephropathy may be greater when embolization is performed following contrast CT
scan, particularly in patients who may already be volume depleted. Contrast-induced
nephropathy and its prevention are discussed in detail elsewhere. (See "Pathogenesis,
clinical features, and diagnosis of contrast-induced nephropathy" and "Prevention of
contrast nephropathy associated with angiography".)

Failure of nonoperative management — Failure of nonoperative management

(observation and/or embolization) is defined as the need for operative intervention and
is generally related to bleeding that becomes apparent by the need for ongoing fluid
resuscitation or transfusion, or hemodynamic instability. Other factors (other than blood
pressure, fluid resuscitation, blood transfusion) identified in a systematic review that
were associated with failure of nonoperative management included peritoneal signs,
Injury Severity Score (ISS), and associated intra-abdominal injuries [51].

Patients who become hemodynamically unstable, by definition, have failed

nonoperative management and should be taken immediately to the operating room for
abdominal exploration. Arteriography with embolization should not be pursued under
these circumstances given the time needed to set up the interventional radiology suite,
get personnel in place, and perform the embolization procedure.

Hypotension may be absolute or relative, or manifested as persistent tachycardia despite

adequate fluid resuscitation. A study using data from the National Trauma Data Bank
(NTDB) identified a trend toward increasing attempts at nonoperative management for
severe liver injuries [32]. Although failure rates for nonoperative management of
hepatic injury are generally low (approximately 7 percent), failed nonoperative
management is associated with an increased mortality [10,37,44,52,53].

In a retrospective review of 591 patients managed nonoperatively for blunt liver injury,
6 percent failed nonoperative management, with approximately one-half of these due to
ongoing bleeding from other injuries [43]. Patients with grade IV or V injuries are more
likely to fail nonoperative management. In one study, logistic regression found that
blood transfusion ≥3 units (odds ratio 10.8, 95% CI 1.6-72.2) was an independent risk
factor for surgical intervention [52]. Most protocols allow for continued observation
with up to 4 units of blood transfusion related to the hepatic injury.

Follow-up care — There are few data to guide the routine care and follow-up of patients
with hepatic injury who have been managed nonoperatively. No definitive
recommendations have been established regarding the need or timing of follow-up
imaging, the need for or duration of bed rest, the timing of return to daily activities
and/or exercise, or the timing to initiate prophylactic or therapeutic anticoagulation
[6,54]. Although it is a common recommendation that patients avoid strenuous activities
for several weeks, this remains intuitive with few data to support this practice [35]. For
patients with higher-grade injuries, we restrict strenuous physical activity for a longer
period of time, which, for grade V injury, can be as long as three months.

SURGICAL MANAGEMENT — The operative management of liver injuries that

require surgical intervention can be a challenge even for experienced surgeons due to
the complex nature of the liver, its size, vascularity, dual blood supply (portal, hepatic
arterial), and its rich and difficult-to-access venous drainage. In hemodynamically
unstable patients, damage control techniques provide temporary control of bleeding and
allow anesthesia staff to resuscitate the patient. Definitive management of bleeding from
the liver is accomplished using a variety of techniques. The surgical management of
hepatic injury is discussed in detail elsewhere. (See "Surgical techniques for managing
hepatic injury".)

MORBIDITY AND MORTALITY — Mortality rates for hepatic injury vary according
to the grade of the injury and have improved over time with the introduction of
nonoperative management strategies and the use of perihepatic packing [17]. Since
mortality is unusual with grade I and II injuries, the greatest reduction in operative
mortality has occurred for higher-grade liver injuries (grade III, IV, V) [24,25,48,55-
58]. Many of these higher-grade injuries can be successfully managed nonoperatively
with overall low mortality rates ranging from 0 to 8 percent. Higher mortality rates are
seen for those patients with high-grade injuries who require surgical management either
immediately or as a result of failed nonoperative management (30 to 68 percent) [31].
Many studies do not include mortality rates related to juxtahepatic injury, for which
mortality rates remain extremely high (77 percent in one series) [26].
Complications are common following the management of liver injuries. The incidence
of complications increases with the grade of liver injury [23,59]. In a series of 669
patients, complications developed in 5, 22, and 52 percent of patients with grade III, IV,
and V injuries, respectively [56]. Complications associated with lower-grade injuries
(grade I, II) are rare.

Biliary tree disruption with formation of biloma and/or persistent bile leak is a frequent
complication of nonoperative management for liver injury. The incidence of bile leak
ranges from 0.5 to 21 percent [44,60-62]. Bile leak manifests as abdominal pain or a
persistent systemic inflammatory response syndrome (SIRS) with fever, tachycardia,
and leukocytosis. Repeat abdominal computed tomography (CT) scan establishes the
diagnosis. Biliary tree disruption with persistent bilious drainage can often be
successfully managed by endoscopic retrograde cholangiopancreatography and stent
placement. However, findings on abdominal CT consistent with bile ascites and/or
persistent hemoperitoneum warrant laparoscopic evaluation with abdominal irrigation
and drainage to remove the bile, which is very irritating to the peritoneum. Findings
consistent with perihepatic abscesses can usually be managed with antibiotics and
percutaneous drainage techniques, but surgery may be needed if interventional
techniques fail to provide adequate drainage [59].

Hepatic necrosis to some extent commonly occurs following angioembolization for

hepatic injury but may also be seen following laparotomy and hepatorrhaphy [48,50].
The combination of hepatic injury and ischemia induced by embolization may
predispose to major hepatic necrosis, particularly in patients who have previously
undergone surgery [50]. Major hepatic necrosis is managed surgically with repeated
resectional debridement in conjunction with interventional drainage procedures, or
hepatic lobectomy [49,50]. Early lobectomy rather than repeated debridement may be
associated with a lower overall complication rate and the need for fewer procedures.
(See "Surgical techniques for managing hepatic injury", section on 'Liver resection'.)

SUMMARY AND RECOMMENDATIONS

●Hepatic injury can result from blunt or penetrating chest or abdominal trauma.
Following blunt trauma, the liver is the most commonly injured organ. Penetrating
injury to the liver is frequently associated with injuries to adjacent structures that can be
associated with mortality rates exceeding 75 percent in some studies. (See 'Introduction'
above and 'Associated injuries' above.)

●We perform initial resuscitation, diagnostic evaluation, and management of the trauma
patient based upon protocols from the Advanced Trauma Life Support (ATLS) program
developed by the American College of Surgeons Committee on Trauma.
Hemodynamically unstable patients with a positive Focused Assessment with
Sonography for Trauma (FAST) exam or diagnostic peritoneal lavage or aspirate
(DPL/DPA) require operative surgical exploration to determine the source of life-
threatening hemorrhage, which may be due to liver injury. (See 'Trauma evaluation'
above and 'Approach to management' above.)

●A suspicion of hepatic injury is increased with right upper quadrant and/or right chest
trauma; however, the clinical history and physical examination are not sufficiently
sensitive or specific for the presence of liver injury. (See "Management of splenic injury
in the adult trauma patient", section on 'Trauma evaluation' and 'Trauma evaluation'
above.)

●Computed tomography (CT) of the abdomen identifies the presence of liver injury and
defines its severity in hemodynamically stable patients. Hepatic injury is graded (I
through VI) depending upon the extent and depth of liver hematoma and/or laceration as
identified on abdominal CT, or at the time of surgery. Higher grades of hepatic injury
correlate with increasing morbidity and mortality. (See 'Hepatic injury grading' above
and 'Morbidity and mortality' above.)

●For hemodynamically stable patients with liver injury with no other indication for
abdominal exploration, we suggest nonoperative management over definitive surgical
intervention, regardless of hepatic injury grade (Grade 2C). Observation involves
monitored care, serial abdominal examination, and serial hemoglobin assessment and
potentially hepatic embolization. Failure of nonoperative management (ongoing
transfusion, hemodynamic instability) indicates the need for hepatic embolization or
surgery. (See 'Nonoperative management' above.)

●For hemodynamically stable patients with liver injury who demonstrate pooling of
intravenous contrast on initial or subsequent abdominal CT scan, we suggest hepatic
embolization rather than nonoperative management without embolization (Grade 2C).
Hepatic embolization requires specialized imaging facilities and an appropriately
trained interventionalist experienced with celiac artery catheterization. Failure of
hepatic embolization to control bleeding indicates the need for surgery. (See 'Hepatic
embolization' above and "Surgical techniques for managing hepatic injury".)

●Mortality has decreased with the introduction of nonoperative management strategies

and damage control techniques. Mortality for low-grade (I, II, III) injuries is rare but
ranges from 10 to 42 percent for high-grade injuries (IV, V, VI). Complications related
to nonoperative management are common and include bile leak that can lead to ascites,
biloma, or abscess, and hepatic necrosis related to angioembolization. (See 'Morbidity
and mortality' above.)