What is the management for liver injury?

Management of Liver Injury

The management of liver injury should be primarily determined by the patient's hemodynamic status, with non-operative management (NOM) being the treatment of choice for all hemodynamically stable patients with liver injuries, regardless of severity grade, in the absence of other internal injuries requiring surgery. 1

Initial Assessment and Diagnosis

• Hemodynamic status assessment: This is the primary determinant for management approach 1
• Diagnostic methods:
  • E-FAST (Extended Focused Assessment with Sonography for Trauma): Rapid tool for detecting intra-abdominal free fluid 1
  • CT scan with intravenous contrast: Gold standard for hemodynamically stable trauma patients 1

Management Algorithm Based on Hemodynamic Status

Hemodynamically Stable Patients (WSES I-III/AAST I-V)

• Non-operative management (NOM) is the treatment of choice 1

• Monitoring requirements:

  • ICU admission for moderate (WSES II/AAST III) and severe (WSES III/AAST IV-V) lesions 1
  • Serial clinical evaluations to detect changes in clinical status 1
  • Continuous monitoring in ICU or ER setting 1

• Adjunctive interventions:

  • Angiography/angioembolization (AG/AE) may be considered as first-line intervention in stable patients with arterial blush on CT scan 1
  • In children, contrast blush on CT is not an absolute indication for AG/AE 1

Transient Responders (WSES II-III/AAST III-V)

• NOM can be considered only in selected settings with:
  • Immediate availability of trained surgeons
  • Operating room access
  • Continuous monitoring
  • Access to angiography/angioembolization
  • Blood and blood products availability
  • Quick transfer system to higher level of care 1

Hemodynamically Unstable Patients (WSES IV)

• Operative management (OM) is indicated 1
• Primary surgical goals:
  • Control hemorrhage
  • Control bile leak
  • Initiate damage control resuscitation 1
• Surgical considerations:
  • Avoid major hepatic resections initially
  • Consider resectional debridement for devitalized tissue in subsequent operations 1
  • Angioembolization for persistent arterial bleeding after non-hemostatic procedures 1
  • REBOA (Resuscitative Endovascular Balloon Occlusion of the Aorta) may be used as a bridge to definitive hemorrhage control 1

Management of Complications

Hemorrhagic Complications

• Delayed hemorrhage without severe hemodynamic compromise: Manage first with AG/AE 1
• Hepatic artery pseudoaneurysm: Manage with AG/AE to prevent rupture 1

Infectious Complications

• Intrahepatic abscesses: Treat with percutaneous drainage 1

Biliary Complications

• Symptomatic or infected bilomas: Manage with percutaneous drainage 1
• Post-traumatic biliary complications: Consider combination of percutaneous drainage and endoscopic techniques 1
• Delayed post-traumatic biliary fistula: Consider lavage/drainage and endoscopic stenting as first approach 1

Supportive Care

Thromboprophylaxis

• Mechanical prophylaxis: Safe and should be considered in all patients without contraindications 1
• LMWH-based prophylaxis: Start as soon as possible following trauma 1
• Anticoagulant reversal: Individualize risk-benefit balance 1

General Support

• Mobilization: Early mobilization for stable patients 1
• Nutrition: Start enteral feeding as soon as possible in the absence of contraindications 1
• Fluid resuscitation: Use balanced crystalloids and/or albumin, followed by vasopressors if needed 2
• Vasopressor support: Norepinephrine as first-line vasopressor 2

Special Considerations

Drug-Induced Liver Injury

• Acetaminophen toxicity: N-acetylcysteine is the antidote and should be administered promptly 3, 4
• Non-acetaminophen drug toxicity: Consider early use of N-acetylcysteine to prevent progression to acute liver failure 5
• Management principles:
  • Discontinue all but essential medications 1
  • Obtain detailed medication history including herbs and supplements 1
  • Determine ingredients of non-prescription medications 1

Mushroom Poisoning

• Antidotes to consider:
  • Penicillin G (300,000 to 1 million units/kg/day IV)
  • Silibinin/silymarin (30-40 mg/kg/day IV or orally for 3-4 days) 1
• Transplantation: List patients for transplantation as this may be the only lifesaving option 1

Pitfalls and Caveats

• Avoid major hepatic resections in the acute setting 1
• Do not delay transfer to a transplantation center when indicated 4
• Remember that most cases of drug-induced liver injury are idiosyncratic and unpredictable 5
• In pediatric patients, NOM should be considered the optimal management approach 1
• Sepsis with multiorgan failure and cerebral edema remain leading causes of death in acute liver failure 6