Severe hepatic trauma – A challenging case

Abstract text (incl. references and figure legends)

CASE HISTORY

A 40-year-old woman suffered thoracoabdominal trauma after trying to stop her moving car, developing a severe hepatic injury.

CLINICAL FINDINGS

The patient was admitted to the emergency room (ER) hemodynamically stable, with abdominal pain and tenderness in the right upper quadrant.

INVESTIGATION/RESULTS

E-FAST was positive, so CT-TAP was performed.

DIAGNOSIS

CT-TAP revealed an isolated severe hepatic injury grade V AAST / III WSES without active bleeding.

THERAPY/PROGRESSIONS

The initial approach was nonoperative management with monitoring in the ICU. On the eighth day, the patient's clinical condition deteriorated. Abdominal paracentesis revealed a choleperitoneum and a laparoscopic exploration and drainage were proposed.

The patient underwent 11 surgical interventions due to recurring hemorrhagic shock, including 7/8 debridement segmentectomy and embolization of a right hepatic artery branch.

She had multiple complications, stayed 53 days at the hospital, 23 days at home hospitalization and was admitted twice to the ER.

The patient is now fully recovered.

COMMENTS

The liver is the most commonly injured organ in blunt abdominal trauma.

Most injuries resolve with nonoperative management and surgery is necessary for only 14% of patients. However, deciding the best treatment for the patient can be a challenge.

The guidelines for the treatment of hepatic trauma have changed considerably. There is a growing consensus that nonoperative therapy is the main treatment if conditions allow. The surgeon must always be prepared to intervene when there's an alteration in the patient's clinical condition.

This challenging case shows that surgeons' experience, knowledge and technical skill greatly influence the patient's prognosis.

REFERENCES

aast@aast.org, Liver Injury Scale 2018

Christmas, A., et al, Management of hepatic trauma in adults, UpToDate, Feb 2022

Coccolini, F., et al, Liver trauma WSES 2020 guidelines, World J Emerg Surg, 2020 15:24

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