What Are the Stages of Liver Damage?

The liver is the largest parenchymal organ in the abdominal cavity and is responsible for important physiological functions of the human body. Hepatocytes are less tolerant to hypoxia, so hepatic arteries and portal veins provide ample blood supply, and bile ducts and blood vessels accompany bile. It is located deep in the right upper abdomen and is protected by the lower chest wall and diaphragm. However, due to the large volume and brittle texture of the liver, once it is easily damaged by violence, intra-abdominal hemorrhage or bile leakage occurs, causing hemorrhagic shock or biliary peritonitis. The consequences are serious, and it must be diagnosed and treated properly.

Basic Information

English name

liverdamage

Visiting department

surgical

Common causes

Knife stab wound, firearm injury, impact, crush

Common symptoms

Hypovolemic shock, peritonitis

Causes of liver injury

According to the cause of injury, liver trauma is generally divided into open injury and closed injury. Open injuries generally include stab wounds and firearm injuries. Stab stab wounds are relatively light and the case fatality rate is low. Firearm injuries are open injuries caused by projectiles powered by gunpowder. They are more common in war injuries. Liver firearm injuries are the most common of abdominal firearm injuries. Open injury can be divided into two types: blind tube injury and penetrating injury. Abdominal closed injuries are more common as blunt injuries, which are mainly caused by impacts and compressions. They are common in road traffic accidents, building collapses, and occasionally falling from heights, sports injuries, or beating injuries.

Because closed injuries of the abdomen are often accompanied by other organ injuries in addition to liver trauma, and there are no signs of injury on the surface of the abdomen, the diagnosis is relatively difficult and the treatment is delayed. Therefore, blunt injuries are more dangerous, and the mortality is often higher than open injuries.

Clinical manifestations of liver injury

Patients with liver trauma generally have a clear history of right thoracic and abdominal trauma, with thirst, nausea, and vomiting. Mainly hypovolemic shock and peritonitis. Some patients with liver trauma have intra-abdominal hemorrhage, and abdominal distension can also appear. Due to different causes of injury, the clinical manifestations of liver trauma are also inconsistent.

Subhepatic hematomas or small hematomas in the liver parenchyma are mainly clinically dull pain in the liver area, and a large liver or upper abdominal mass can be seen on examination. If the hematoma communicates with the biliary tract, it is manifested as biliary tract hemorrhage, which causes upper gastrointestinal bleeding. Long-term repeated bleeding can lead to chronic progressive anemia. If the hemorrhage in the hematoma continues to increase, the liver capsule tension is too large, it suddenly ruptures under the action of external force, and acute hemorrhagic shock occurs. Therefore, for patients with subcapsular hematoma, non-surgical treatment must pay attention to the possibility of delayed bleeding. If the hematoma is infected secondaryly, signs of liver abscess such as chills, high fever, and pain in the liver area may appear.

In the case of superficial liver laceration, due to less bleeding, less bile extravasation, and more bleeding can stop on its own in a short period of time, generally only right upper quadrant pain, shock and peritonitis rarely occur.

Central liver rupture or open liver injury has a wide range of liver tissue fragmentation, and generally involves large blood vessels and bile ducts. Abdominal hemorrhage and bile extravasation are frequent. Patients with liver trauma often have symptoms of acute shock and peritoneal irritation. It manifests as abdominal pain, pale face, pulse count, decreased blood pressure, and decreased urine output. Abdominal tenderness is obvious, and the abdominal muscles are tense. As bleeding increases, the symptoms mentioned above get worse.

When the liver is severely fragmented or the large blood vessels near the hilum are ruptured, such as portal vein, inferior vena cava, etc., major bleeding that is difficult to control can occur. Large blood vessel injury can lead to a large amount of dynamic blood loss and cause fatal hypovolemic shock, often dying during the treatment process and losing the opportunity for surgical treatment.

Liver injury examination

Laboratory inspection

There was no significant change in the early stage of mild liver trauma. Due to rapid blood loss and blood concentration, many patients do not show changes in hemoglobin, but patients with liver trauma may have an increased white blood cell count.

2. Auxiliary inspection

(1) Abdominal puncture is of great value in diagnosing rupture of abdominal organs, especially for parenchyma. Visceral injury can be considered as a result of non-coagulated blood. However, there may be false negative results when the amount of bleeding is small, so a negative single puncture cannot exclude visceral damage. If necessary, make multiple punctures at different locations and at different times, or perform a diagnostic lavage of the abdominal cavity to help diagnosis.

(2) Regularly measure the hematocrit, hemoglobin, and hematocrit to observe the dynamic changes. If there is progressive anemia, it indicates internal bleeding.

(3) B-mode ultrasonography can not only find hemorrhage in the abdominal cavity, but also be helpful for the diagnosis of hepatic subcapsular hematoma and intrahepatic hematoma, which is more commonly used clinically.

(4) If X-ray examination has subhepatic hematoma or intrahepatic hematoma, the X-ray film or fluoroscopy can show enlarged liver shadow and diaphragmatic muscle elevation. If free gas is found at the same time, it is suggested that the cavity organs are damaged.

(5) Liver radionuclide scans are not clear in the diagnosis of closed injuries, and patients with subhepatic or intrahepatic hematomas are suspected. The injury is not urgent. Patients can be used for isotope liver scans when conditions permit. Hematoma showed radiation defect in the liver.

(6) Hepatic arteriography can be used for closed injuries that are indeed difficult to diagnose, such as intrahepatic hematomas, and those who are not very urgent. Intra-hepatic artery branch aneurysm formation or contrast agent spillovers have diagnostic significance. Not as a routine check.

Liver injury diagnosis

Open liver injury is easier to diagnose, but it is also necessary to pay attention to whether there is a combined thoracoabdominal injury. Patients with closed injury accompanied by typical hemorrhagic shock and peritoneal irritation are easily diagnosed with a history of trauma. However, for some patients with liver trauma with concomitant injuries, such as unconsciousness of brain trauma, multiple fractures with shock, and elderly and infirm patients who are slow to respond should be vigilant to avoid missed diagnosis. Patients with liver cirrhosis or liver cancer with mild trauma can cause liver rupture and should not be taken lightly. Whether the closed abdominal injury is associated with liver injury involves the question of open surgery, so the accuracy of the diagnosis is high. When the diagnosis is in doubt, abdominal puncture, lavage and other auxiliary examinations can help the diagnosis.

Liver injury treatment

The first thing to consider is the patient's general condition and whether there are compound injuries, such as brain, lung, and bone injuries. Determine a reasonable treatment plan based on the general condition and the severity of the combined injury. Patients with simple liver injury are actively preparing for surgery while actively correcting hemorrhagic shock.

Emergency treatment

Keep the airway open and give adequate oxygen. Quickly establish more than two venous channels to ensure smooth blood transfusion and avoid insufficient blood perfusion of important organs. When the condition improves and is stable, make the necessary examinations and make further treatment plans after the diagnosis is clear. Patients with severe shock can be actively operated at the same time as blood transfusion and fluid replacement.

2. Non-surgical treatment

Indications for non-surgical treatment:

(1) Patients with grade , or hematoma (AAST classification) without active bleeding and non-progressive enlargement of hematoma

(2) Hemodynamically stable patients, the bleeding volume does not exceed 600ml.

(3) The symptoms of peritoneal inflammation are mild, and the patient is clear enough to cooperate with the physical examination.

(4) There were no intra-abdominal injuries. The above conditions can be temporarily not treated under the condition of dynamic monitoring of vital signs, hemoglobin, and abdominal circumference.

Patients should be absolutely bed rested for more than 2 weeks, sedative pain, blood transfusion, rehydration, prevention of infection, and proper use of hemostatic drugs. The choice of antibiotics is based on the bacteria that may be present in the bile. Hemostatic drugs are used in combination with procoagulant and antifibrinolytic drugs, and small vasoconstrictors if necessary. Gastrointestinal decompression can be performed in patients with bloating to promote the recovery of gastrointestinal function and facilitate the absorption of blood in the abdomen. Selective hepatic arteriography can be performed in some patients, and embolization can be performed after finding the bleeding lesions.

3. Surgical treatment

When patients with liver trauma have obvious intra-abdominal hemorrhage, peritoneal inflammation symptoms or combined internal organ injuries, they should perform laparotomy while correcting shock. The basic principles of surgery are:

(1) Hemostasis;

(2) ligating bile ducts;

(3) Clear necrotic liver tissue;

(4) drainage;

(5) Deal with combined injuries.