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Abdominal Trauma

Extra Edge:
Most common organ injured in blunt abdominal trauma is spleen.
Bowel most common injured in blunt abdominal trauma is Jejunum.
Penetrating abdominal trauma most common organ injured is ileum.
  1. Liver Trauma
Liver is the second most common organ involved in blunt trauma,
Most liver injures involve segment VI, VII & VIII

  1. Signs/ symptoms are related to blood loss, peritoneal irritation, and guarding. Rebound tenderness is common but nonspecific.
  2. FAST (Focused abdominal assessment by sonography for trauma) replace DPL.
  3. Occasionally, patients may subsequently develop a liver abscess.
  4. Signs of blood loss, such as shock, hypotension, and a falling hematocrit level, may dominate the picture.
  5. Diagnostic peritoneal lavage is useful in evaluating patients with blunt abdominal trauma, with reported sensitivities as high as 95%.
  • Preferred Examination:
  1. Contrast-enhanced CT scanning remains the examination of choice in patients with blunt abdominal trauma with stable vital patient.
  2. Most sensitive investigation for hemoperitoneum is DPL.
  3. Radionuclide study with technetium-99m iminodiacetic acid (IDA) is the examination of choice in patients in whom bile leaks are suspected.
  4. Magnetic resonance cholangiopancreatography (MRCP) may be used for the diagnosis and follow-up observation of bile duct injuries.
  5. Angiography is useful to localize the site of hemorrhage and provide an opportunity for the interventional transcatheter embolization of bleeding sites.
  6. 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. CT criteria for staging liver trauma based on the.
  • CT grading of liver injury
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
Grade 2 -  Parenchymal laceration 1-3 cm deep &parenchymal/subcapsular hematomas 1-3 cm thick
Grade 3 - Parenchymal laceration more than 3 cm deep and parenchymal or subcapsular hematoma more than 3 cm in diameter
Grade 4 - Parenchymal/subcapsular hematoma more than 10 cm in diameter, lobar destruction, or devascularization or 1-3 segmentcol injury
Grade 5 - Global destruction or devascularization of the liver or more than 3 segment injury
Grade 6 - Hepatic avulsion

Extra Edge:
  1. Blunt hepatic trauma more often causes venous injury and hemorrhage.
  2. Most arterial injuries are increasingly being caused by radiologic interventional procedures such as liver biopsy,
  3. TIPS, PTC, and biliary drainage.
  4. The typical injury is a small pseudoaneurysm, which may require meticulous superselective angiography.
  5. A combined surgical and radiologic approach may be required in the treatment of patients with high-grade liver lacerations with injury to the retrohepatic inferior vena cava. Initially, the surgeon attempts to control the hemorrhage by temporary perihepatic packing.
  6. Recurrent liver parenchymal bleeding can be treated successfully by using transcatheter embolization, and bleeding from a major hepatic vein can be controlled by placing an intravenous stent.
  7. Embolization can be performed in persistent arterial hemorrhage, as may occur with stab wounds of the liver, and in the occlusion of pseudoaneurysms.
  8. Transcatheter arterial embolization may reduce transfusion requirements and allow healing of hepatic injuries without surgery.
  9. Because hepatic arteries are not end arteries, occlusive devices should be deployed distal to the lesion to prevent collateral backdoor filling.
  10. The entire hepatic artery may be occluded, if required, as long as the portal vein is patent.
  11. If the portal vein is occluded, only selective embolization can be performed; this should prevent liver infarction due the presence of intrahepatic collaterals.
Algorithm for the initial evaluation of a patient with Penetrating abdominal trauma
AASW = anterior abdominal stab wound; CT = computed tomography; DPL = diagnostic peritoneal lavage; GSW = gunshot wound; LWE = local wound exploration; RUQ = right upper quadrant; SW = stab wound.

Ref: Schwartz's Principles of Surgery 9th Edition Ch 7
Algorithm for the initial evaluation of a patient with suspected blunt abdominal trauma

King's College Selection Criteria for Liver Transplantation in Acute Liver Failure Ref: Schwartz's Principles of Surgery 9th Edition Ch 31
Cause Selection Criteria
Acetaminophen Arterial pH <7.30 irrespective of hepatic coma grade
  Prothrombin time >100 s + serum creatinine level >3.4 mg/dL + grade III or IV hepaticcoma
Not acetaminophen Prothrombin time >100 s irrespective of hepatic coma grade
  Any three of the following, irrespective of hepatic coma grade:
  Cryptogenic or drug-induced hepatitis
  Jaundice to coma interval >7 d
  Prothrombin time >50 s
  Serum bilirubin level >17.5 mg/Dl
  Age <10 y or >40 y

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