Hepatic Trauma

 Intraparenchymal &/or subcapsular hematoma

image Injury to bare area of liver may result in retroperitoneal, not intraperitoneal, bleeding
• Best imaging tool: MDCT in hemodynamically stable patients
• CT protocol advice: Rapid bolus of contrast; include lung bases and pelvis
• Angiography to localize active hemorrhage and embolization to control it

TOP DIFFERENTIAL DIAGNOSES

• HELLP syndrome
• Spontaneous hemorrhage (coagulopathy)
• Bleeding hepatic tumor (e.g., hepatocellular carcinoma or adenoma)

PATHOLOGY

• Blunt trauma is most common cause of hepatic injury

CLINICAL ISSUES

• Clinical profile: Patient with history of motor vehicle accident, right upper quadrant tenderness, guarding, and hypotension
• Mortality: 10-20%
• Liver is 2nd most frequently injured solid intraabdominal organ after spleen

DIAGNOSTIC CHECKLIST

• CT evidence of active extravasation
image Intra- or extrahepatic collection, i sodense with vessels
image Usually indicates need for embolization or surgery, regardless of grade of injury
• Laceration of left hepatic lobe is often associated with bowel and pancreatic injury
image
(Left) CT in a 37-year-old man who sustained blunt abdominal trauma in a motor vehicle accident shows a large right lobe hepatic injury (laceration & infarct or parenchymal hematoma) with high-attenuation active arterial extravasation image.

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(Right) Selective right hepatic artery angiogram in the same patient confirms active bleeding image, which was successfully treated with a coil embolization. The patient made an uneventful recovery without the need for a blood transfusion.
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(Left) Axial CECT obtained in a 19-year-old man who sustained multiple injuries after a motorcycle accident demonstrates a right lobe hepatic laceration with active bleeding image.

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(Right) Axial CECT in the same patient shows extension of active bleeding image into the peritoneal cavity along the hepatic capsule. Due to the acute intraperitoneal bleeding, urgent surgery was performed, which revealed an actively bleeding capsular artery.

TERMINOLOGY

Definitions

• Liver or hepatic injury

IMAGING

General Features

• Best diagnostic clue
image CT evidence of irregular parenchymal lesions with intra- and perihepatic hemorrhage
• Location
image Right lobe (75%), left lobe (25%)
– Intraparenchymal &/or subcapsular hematoma

CT Findings

• Lacerations: Simple or stellate (often parallel to portal/hepatic vein branches)
image Simple: Hypodense, solitary, linear laceration
image Stellate: Hypodense, branching, linear lacerations
• Parenchymal and subcapsular hematomas (lentiform configuration)
image Unclotted blood (35-45 HU) soon after injury
– NECT: May be hyperdense to normal liver
– CECT: Hypodense to enhancing normal liver tissue
image Clotted blood (60-90 HU)
– Hyperdense to unclotted blood and normal liver
– May be hyperdense to unenhanced liver
– “Sentinel clot” helps to localize source of bleeding
• Active hemorrhage or pseudoaneurysm
image CECT: Active hemorrhage
– Isodense to enhanced vessels
– Extravasated contrast materia l (85-350 HU) surrounding low-attenuation clot
• Hemoperitoneum: Perihepatic and peritoneal recess blood collections
image Injury to bare area of liver may result in retroperitoneal, not intraperitoneal, bleeding
• Periportal tracking: Linear, focal, or diffuse periportal zones of decreased HU
image Due to dissecting blood, bile, or dilated periportal lymphatics
image Differential diagnosis: Overhydration; check for distended inferior vena cava (IVC)
– Increased venous pressure and transudation
• Areas of infarction
image Small or large areas of low attenuation
image Usually wedge-shaped; segmental or lobar
image Intrahepatic/subcapsular gas (due to hepatic necrosis)
image May be due to trauma itself or iatrogenic (following surgery or coil embolization for active bleeding)
• CT diagnosis of liver trauma
image Accuracy (96%), sensitivity (∼ 100%), specificity (94%)

MR Findings

• T1WI and T2WI
image Varied signal intensity depending on degree/age of hemorrhage or infarct

Ultrasonographic Findings

• Grayscale ultrasound
image Subcapsular hematoma: Lentiform or curvilinear fluid collection
– Initially: Anechoic
– After 24 hours: Echogenic
– 4-5 days: Hypoechoic
– 1-4 weeks: Internal echoes, septations develop within hematoma
image Intraparenchymal hematoma
– Rounded echogenic or hypoechoic foci
image Bilomas
– Rounded/ellipsoid, anechoic, loculated structures
– Well-defined sharp margins close to bile ducts
image Parenchymal tears
– Irregular defects
– Abnormal echotexture relative to normal liver
Nov 16, 2016 | Posted by in GASTROINTESTINAL IMAGING | Comments Off on Hepatic Trauma

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