Liver Injury Overview and Aetiology
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Questions and Answers

What is a common treatment method for necrotic tissue in the liver?

  • High-dose corticosteroids
  • Systemic antibiotics and aspiration under ultrasound guidance (correct)
  • Topical antiseptic application
  • Surgical resection only

    • Which procedure is recommended for managing biliary fistulas if initial treatments fail?

  • General observation without intervention
  • Percutaneous transhepatic drainage or stent insertion (correct)
  • Chemotherapy followed by surgical intervention
  • Transplantation of the affected liver segment

    • What is the typical response of the liver after extensive trauma, according to recovery expectations?

  • Permanent damage without any regenerative ability
  • Likely to lead to multiple organ failure
  • Sluggish recovery with extensive scarring
  • Remarkable recovery with rapid parenchymal regeneration (correct)

    • What is the initial treatment for a dominant extrahepatic bile duct stricture associated with obstructive jaundice?

    <p>Endobiliary balloon dilatation or stenting (A)</p> Signup and view all the answers

    How can vascular complications in the liver be treated nonsurgically?

    <p>Transarterial embolisation by a specialist interventional radiologist (A)</p> Signup and view all the answers

    What is the primary purpose of diagnostic peritoneal lavage (DPL) in cases of suspected abdominal injury?

    <p>To identify the presence of free intraperitoneal fluid (D)</p> Signup and view all the answers

    In a patient with a penetrating abdominal wound and haemodynamic instability, what is the recommended immediate action?

    <p>Transfer directly to the operating theatre (A)</p> Signup and view all the answers

    Which test is particularly useful for diagnosing free intraperitoneal fluid in trauma cases?

    <p>FAST (C)</p> Signup and view all the answers

    What is a critical step in the initial management of patients with severe abdominal injuries?

    <p>Maintenance of airway patency, breathing, and circulation (A)</p> Signup and view all the answers

    Which of the following interventions should be prioritized for patients with suspected haemothorax?

    <p>Insertion of intercostal chest drains (B)</p> Signup and view all the answers

    What is a potential consequence of neglecting to transfer a patient with massive blood loss to the operating theatre promptly?

    <p>Increased risk of coagulopathy (B)</p> Signup and view all the answers

    What type of scan is recommended for haemodynamically stable patients after initial management?

    <p>Contrast enhanced CT scan (A)</p> Signup and view all the answers

    What is the primary focus when addressing liver injuries during surgery?

    <p>Arresting the bleeding (B)</p> Signup and view all the answers

    What method can be used to temporarily control brisk liver hemorrhage during surgery?

    <p>Temporary packing and Pringle's manoeuvre (A)</p> Signup and view all the answers

    Why should suturing liver tears be avoided whenever possible?

    <p>It may lead to infection or bile duct communication (A)</p> Signup and view all the answers

    What complication can arise from a liver haematoma that communicates with a torn bile duct?

    <p>Haematobilia (B)</p> Signup and view all the answers

    In which scenario is suturing of liver tears most likely to be deemed necessary?

    <p>When control of bleeding vessels is impossible in deep tears (C)</p> Signup and view all the answers

    What is the best approach to manage a shattered liver lobe that cannot be salvaged?

    <p>Excision of the lobe (C)</p> Signup and view all the answers

    What should be the immediate action upon the arrival of a patient requiring fresh frozen plasma and cryoprecipitate?

    <p>Discuss with the blood transfusion service about the necessity of these components. (D)</p> Signup and view all the answers

    What does thromboelastography (TEG) assist with in patients with acute loss of clotting factors?

    <p>It helps in making empiric decisions regarding factor administration. (D)</p> Signup and view all the answers

    What precaution is routinely taken after managing liver trauma?

    <p>Placement of multiple intraperitoneal drains (D)</p> Signup and view all the answers

    What is a possible consequence of inadequate management of liver injuries?

    <p>Death from blood loss (C)</p> Signup and view all the answers

    In which situation should a laparotomy be performed immediately?

    <p>For patients who are haemodynamically unstable. (A)</p> Signup and view all the answers

    What imaging should be considered for haemodynamically stable patients prior to laparotomy?

    <p>A contrast CT scan to evaluate the nature of the injury. (D)</p> Signup and view all the answers

    Which of the following indicates a complication from penetrating liver trauma?

    <p>Abscess formation (D)</p> Signup and view all the answers

    What is the role of prophylactic antibiotics in liver trauma management?

    <p>To avoid post-operative infections (A)</p> Signup and view all the answers

    What indicates the need to discontinue conservative treatment for blunt liver injury?

    <p>Emergence of generalised peritonitis. (B)</p> Signup and view all the answers

    What are the consequences of ignoring reimaging for patients with vascular injury indications?

    <p>Potentially treatable false aneurysms may develop. (A)</p> Signup and view all the answers

    What is the role of interventional radiology in managing liver trauma?

    <p>To assist in the control of hepatic artery bleeding through embolization. (A)</p> Signup and view all the answers

    What is a typical characteristic of patients suitable for conservative management of blunt liver injuries?

    <p>They must be haemodynamically stable without peritonitis. (B)</p> Signup and view all the answers

    How should a subcapsular or intrahepatic hematoma be managed?

    <p>It requires conservative management to resolve spontaneously. (D)</p> Signup and view all the answers

    What is the primary purpose of the Pringle maneuver during liver surgery?

    <p>To control bleeding from the liver (D)</p> Signup and view all the answers

    What is a critical step to take if there is direct damage to the portal vein during surgery?

    <p>Repair the damage to the vein (C)</p> Signup and view all the answers

    What vascular complication is associated with unavoidable ligation of the hepatic artery?

    <p>Necrosis of liver tissue (D)</p> Signup and view all the answers

    During laparotomy, a specific incision is recommended to provide excellent access to which organs?

    <p>Liver and spleen (C)</p> Signup and view all the answers

    After hepatic surgery, what should be done to manage potential fluid collection?

    <p>Leave a closed suction drainage system in situ (A)</p> Signup and view all the answers

    What is the recommended suture material for repairing portal vein injuries?

    <p>5/0 Prolene (D)</p> Signup and view all the answers

    What complication can arise from major hepatic vein injuries during surgery?

    <p>Warm ischaemia of the liver (C)</p> Signup and view all the answers

    Which procedure is used as a workaround when the direct repair of the portal vein is not technically feasible?

    <p>Venovenous bypass (B)</p> Signup and view all the answers

    What is the best approach to handle a stab incision on the liver?

    <p>Suture it with fine absorbable monofilament (C)</p> Signup and view all the answers

    What should be avoided during hepatic injury repair to ensure better outcomes?

    <p>Using omentum to pack (B)</p> Signup and view all the answers

    Flashcards

    Crushing Injury to Lower Chest/Upper Abdomen

    Severe injury to the lower chest/upper abdomen often involving rib fractures, internal bleeding, and damage to the spleen and/or liver.

    Diagnostic Peritoneal Lavage (DPL)

    A test to detect blood in the abdomen. It involves injecting saline into the abdomen and analyzing the withdrawn fluid.

    Ultrasound

    A technique that uses sound waves to visualize the abdomen.

    CT Scan

    A scan that uses X-rays and contrast dye to create detailed images of the chest and abdomen.

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    Laparotomy

    An emergency procedure to assess and treat injuries to the abdomen.

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    Advanced Trauma Life Support (ATLS)

    A medical approach that prioritizes airway, breathing, and circulation during trauma.

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    Haemorrhagic Shock

    A condition characterized by low blood pressure, rapid heart rate, and pale skin due to blood loss.

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    Blunt Liver Injury

    A serious condition that occurs when the liver is injured by a blunt force, such as a car accident. This can lead to bleeding inside the liver, which can be life-threatening.

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    Thromboelastography (TEG)

    A type of blood test that measures the time it takes for blood to clot. It can be used to assess the severity of liver injury and guide treatment decisions.

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    Contrast CT

    A medical procedure that uses X-rays and a contrast dye to create images of the liver and surrounding structures. It is used to diagnose and monitor liver injuries.

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    Embolization

    A medical procedure that uses a catheter to deliver a substance that blocks blood flow to a specific area of the liver. It is used to control bleeding and prevent further damage.

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    Liver Failure

    A condition where the liver is not functioning properly. This can occur after a liver injury and can lead to serious complications.

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    Hematoma

    A medical condition that involves a collection of blood inside the liver.

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    Hepatic Artery Bleeding Control

    A medical intervention that aims to stop bleeding from the liver.

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    Conservative Management

    The medical practice of monitoring and observing a patient without performing any surgery.

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    Bile Collection

    A collection of bile in the liver, usually caused by trauma or obstruction. Often requires drainage under ultrasound guidance.

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    Biliary Fistula

    An abnormal connection between the bile ducts and a blood vessel, usually the hepatic artery or portal vein. Can lead to bleeding into the bile duct (haemobilia) or other complications.

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    Pringle's Maneuver

    A procedure to temporarily stop blood flow to the liver during surgery by clamping off the portal vein and hepatic artery. Used to control bleeding during liver trauma.

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    Hepatic Artery Aneurysm

    A widening or weakening of a blood vessel in the liver, often caused by trauma. Can lead to bleeding and other complications. Best treated by embolising the vessel.

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    Liver Regeneration

    The liver's ability to regenerate after trauma, often leading to complete restoration of function.

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    8Rooftop9 Incision

    A surgical approach for accessing the liver and spleen, often involving a midline incision extending to the xiphisternum.

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    Angioembolisation

    A surgical procedure used to repair damaged blood vessels in the abdomen.

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    Portal Vein

    The main vein that carries blood from the intestines to the liver.

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    Veno-venous Bypass

    A temporary method used to restore blood flow to the liver after surgery by diverting blood flow from the femoral vein to the superior vena cava.

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    Warm Ischemia Time

    The time during which the liver can tolerate a lack of blood flow without damage.

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    Inferior Vena Cava (IVC)

    The main vein that carries blood from the lower body to the heart.

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    Deceleration Injury

    A type of injury often seen in traffic accidents, where tearing occurs in the liver tissue near the attachments.

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    Inflow Occlusion

    A technique used to control bleeding during liver surgery by temporarily stopping blood flow to the liver.

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    Liver Injury Bleeding Risk

    Most liver injuries stop bleeding by the time a surgeon explores them, but some can be fatal due to blood loss.

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    Brisk Liver Hemorrhage

    Bleeding from a liver injury that continues despite attempts to stop it, usually in deep tears.

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    Liver Hematoma

    The buildup of blood within the liver after an injury, sometimes leading to complications.

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    Haematobilia

    A condition where blood leaks from a damaged bile duct into the gastrointestinal tract after a liver injury.

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    Conservative Liver Injury Management

    The practice of observing and monitoring a patient with a liver injury without immediate surgery.

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    Liver Lobe Excision

    A surgical procedure to remove damaged or diseased parts of the liver.

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    Liver Tear Suturing

    Suturing a liver tear to control bleeding, often used for deep tears when other methods fail.

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    Pedicled Omentum Suturing

    A technique used to stop bleeding in deep liver tears by tying sutures over a piece of omentum (fatty tissue) that helps to control bleeding.

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    Multiple Intraperitoneal Drains

    A procedure to drain accumulated blood and bile after a liver injury, typically using multiple drains placed in the abdominal cavity.

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    Study Notes

    Liver Injury

    • The liver is the second most common organ injured in abdominal trauma, after the spleen.
    • Liver injuries are often associated with damage to other abdominal organs (e.g., ribs, pleura, lungs, colon, spleen).
    • Liver injury prognosis depends on the associated injuries; mortality averages 15-20%.

    Liver Injury Aetiology

    • Blunt trauma: Direct impact; commonly causes contusion, laceration, and avulsion of the liver. Often associated with other injuries (spleen, kidney). More frequent and has higher mortality than penetrating injuries.
    • Penetrating trauma: Stab or gunshot wounds; often associated with chest or pericardial involvement; may or may not require surgery.
    • Iatrogenic injury: Increasingly common due to percutaneous procedures (e.g., liver biopsy, cholangiography).
    • Spontaneous rupture: Extremely rare, can be associated with conditions like eclampsia or certain liver tumours.

    Liver Injury Pathology

    • Severity of injury: Classified into increasingly serious types
      • Small subcapsular hematoma
      • Small superficial tear(s)
      • Large subcapsular or intrahepatic hematoma
      • Large deep tear(s)
      • Shattered liver parenchyma (including a whole lobe)
      • Vascular injury (main hepatic veins are most difficult to manage)

    Initial Management of Liver Injuries (Penetrating)

    • ABCs: Airway, breathing, and circulation are paramount.
    • Access: Two large-bore IVs, blood samples for tests (cross-matching, CBC, urea, electrolytes, liver function tests, clotting times, glucose, amylase)
    • Volume replacement: Blood products (initial volume replacement).
    • Diagnosis: Arterial blood gases, intubation and ventilation when necessary, chest drains if pneumothorax/hemothorax suspected.
    • Transfer: If stable, CT scan of the abdomen and chest; Immediate transfer to the operating room.
      • Resuscitation continue on the operating table.
      • Fresh frozen plasma and cryoprecipitate availability should be confirmed.

    Blunt Liver Trauma Management

    • Unstable patients: Immediate laparotomy is required.
    • Stable patients: CT scan to evaluate the extent of the injury and associated vascular/biliary structures.
    • Conservative management: Possible for those who are stable. Ongoing monitoring with repeat CT scans is essential. Ongoing blood loss, evidence of coagulopathy, or developing peritonitis indicate a need for surgery.

    Surgical Management of Liver Trauma

    • Access: Wide incision, (extended to the chest if needed).
    • Exploration: Comprehensive and careful abdominal exploration.
    • Bleeding control: Local control (suturing bleeding vessels, using packing materials); rarely shunting techniques, angioembolization.
    • Repair or resection/ligation: Repair tears, control major injuries. Excision of severely damaged lobes if needed.
    • Intra/peri-operative procedures: Pringle’s maneuver and hepatic artery control, ligation.
    • Post-operative measures: Multiple intraperitoneal drains to prevent fluid collections, prophylactic antibiotics.

    Biliary Injuries

    • Classification: Leaks, transections, occlusion (ligation/stricture), or a combination. Iatrogenic injury following cholecystectomy is more common than traumatic injury.
    • Symptoms: Abdominal pain, nausea, anorexia, abdominal distention, (less commonly ascites and bile peritonitis).
    • Diagnosis: Ultrasound (fluid collections), radionuclide biliary scintigraphy (ongoing leakage), CT scan, (HIDA scan - highly accurate for diagnosis).
    • Treatment: Roux-en-Y choledochojejunostomy for repair of transected bile ducts. Conservative management or surgery depending on severity, extent and stability.

    Complication/Other notes

    • Abscess formation
    • Bile leakage
    • Vascular complications (hepatic artery aneurysm, arteriovenous fistulae and arteriobiliary fistulae).
    • Liver failure
    • Hepatic injury long-term complications - strictures, abscesses
    • Treatment approach for stable and unstable patients.

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    Description

    This quiz covers the critical aspects of liver injuries, including their causes, associated injuries, and prognosis. Understand both blunt and penetrating trauma's impact on the liver, alongside considerations of iatrogenic and spontaneous injuries. Test your knowledge on this significant topic in abdominal trauma.

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