What is the management approach for a liver subcapsular hematoma?

Management of Liver Subcapsular Hematoma

Non-operative management (NOM) should be the treatment of choice for all hemodynamically stable patients with liver subcapsular hematoma, regardless of severity, in the absence of other internal injuries requiring surgery. 1

Initial Assessment and Management

Diagnostic Approach

• Hemodynamic status determines the diagnostic method selection 1:
  • E-FAST (Extended Focused Assessment with Sonography for Trauma) is rapid for detecting intra-abdominal free fluid
  • CT scan with intravenous contrast is the gold standard for hemodynamically stable patients
  • Serial clinical evaluations and laboratory testing must be performed to detect changes in clinical status

Management Algorithm Based on Hemodynamic Status

For Hemodynamically Stable Patients:

1. Non-operative management (NOM) is first-line treatment 1

   • Applies to all severity grades (WSES I-III/AAST I-V) without other injuries requiring surgery
   • CT scan with IV contrast should always be performed before NOM
   • Intensive care monitoring for moderate (WSES II/AAST III) and severe (WSES III/AAST IV-V) lesions

2. Angiography/Angioembolization (AG/AE)

   • Consider as first-line intervention in stable patients with arterial blush on CT scan 1
   • Particularly useful for delayed hemorrhage without severe hemodynamic compromise

For Hemodynamically Unstable Patients:

1. Operative Management (OM) is indicated 1

   • Primary surgical goals: control hemorrhage and bile leak
   • Damage control resuscitation should be initiated as soon as possible
   • Major hepatic resections should be avoided initially

2. Adjunctive Measures

   • Angioembolization for persistent arterial bleeding after surgical procedures
   • REBOA (Resuscitative Endovascular Balloon Occlusion of the Aorta) may be used as a bridge to definitive hemorrhage control

Management of Complications

Bleeding Complications

• Re-bleeding/secondary hemorrhage (1.7-5.9% of cases) 1
  • 69% of "late" bleeding can be managed non-operatively
  • Angioembolization is preferred for delayed hemorrhage without severe hemodynamic compromise

Hepatic Artery Pseudoaneurysm

• Prevalence of approximately 1% 1
• Should be managed with AG/AE to prevent rupture, even if asymptomatic

Biliary Complications (2.8-30% incidence) 1

• Bilomas: Most regress spontaneously; symptomatic or infected bilomas require percutaneous drainage
• Biliary fistulas: Consider combination of percutaneous drainage and endoscopic techniques
• For post-traumatic biliary fistula: Laparoscopic lavage/drainage and endoscopic stenting as first approach

Infectious Complications

• Intrahepatic abscesses (0.6-7% prevalence) 1
  • Treated with CT or ultrasound-guided percutaneous drainage
  • Surgical management may be needed for hepatic necrosis affecting patient condition

Supportive Care

Thromboprophylaxis

• Mechanical prophylaxis for all patients without contraindications 1
• LMWH-based prophylaxis should be started as soon as safely possible

Nutrition and Mobilization

• Early enteral feeding in the absence of contraindications 1
• Early mobilization for stable patients

Special Considerations

Minimally Invasive Approaches

• Laparoscopy should be considered in cases of delayed surgery 1
• In selected cases where intra-abdominal injury is suspected days after initial trauma, interval laparoscopic exploration may extend NOM

Resource-Limited Settings

• NOM may still be considered with hemodynamic stability, negative serial physical examinations, and negative imaging/blood tests 1
• Close monitoring remains essential

The management approach should be tailored to the patient's hemodynamic status, with NOM being preferred whenever possible to minimize morbidity and mortality while effectively managing this potentially life-threatening condition.