What is the management approach for liver laceration versus hematoma?

Management Approach for Liver Laceration versus Hematoma

The management of liver trauma 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 whether they present as lacerations or hematomas. 1

Initial Assessment and Diagnosis

• The diagnostic approach should be determined by the patient's hemodynamic status upon presentation 1
• Extended Focused Assessment with Sonography for Trauma (E-FAST) is rapid and effective for detecting intra-abdominal free fluid in the initial evaluation 1
• CT scan with intravenous contrast is the gold standard for evaluating liver injuries in hemodynamically stable patients and should always be performed in patients being considered for NOM 1
• CT findings help distinguish between lacerations (disruptions of liver parenchyma) and hematomas (collection of blood within the liver substance or subcapsular space) 2, 3

Management Algorithm Based on Hemodynamic Status

For Hemodynamically Stable Patients (Both Laceration and Hematoma)

• NOM should be the treatment of choice for all hemodynamically stable minor (WSES I/AAST I-II), moderate (WSES II/AAST III), and severe (WSES III/AAST IV-V) injuries in the absence of other internal injuries requiring surgery 1
• Serial clinical evaluations (physical exams and laboratory testing) must be performed to detect changes in clinical status during NOM 1
• Intensive care unit admission is required only for moderate (WSES II/AAST III) and severe (WSES III/AAST IV-V) lesions 1
• Angiography/angioembolization (AG/AE) may be considered as a first-line intervention in hemodynamically stable patients with arterial blush on CT scan 1
• In selected cases where an intra-abdominal injury is suspected in the days after the initial trauma, interval laparoscopic exploration may be considered as an extension of NOM 1, 4

For Hemodynamically Unstable Patients (Both Laceration and Hematoma)

• Hemodynamically unstable and non-responder patients (WSES IV) should undergo operative management (OM) 1
• Primary surgical intention should be to control hemorrhage and bile leak while initiating damage control resuscitation 1
• At laparotomy, if no major bleeding is present, compression alone or electrocautery, bipolar devices, argon beam coagulation, topical hemostatic agents, simple suture of the hepatic parenchyma, or omental patching may be sufficient to stop the bleeding 1
• For major hemorrhage, more aggressive procedures including manual compression and hepatic packing, ligation of vessels in the wound, hepatic debridement and finger fracture, balloon tamponade, or shunting procedures may be used 1, 5
• Major hepatic resections should be avoided initially and only considered in subsequent operations for large areas of devitalized liver tissue 1
• Angioembolization is useful for persistent arterial bleeding after non-hemostatic or damage control procedures 1
• Resuscitative endovascular balloon occlusion of the aorta (REBOA) may be used in hemodynamically unstable patients as a bridge to other more definitive procedures for hemorrhage control 1

Management of Specific Types of Liver Injuries

Liver Lacerations

• Simple lacerations limited to the bare area may not cause intraperitoneal bleeding and can often be managed non-operatively with close observation 2
• Complex lacerations involving vascular structures require more aggressive monitoring and may need intervention if bleeding persists 3
• Laparoscopic approaches may be considered for selected cases of liver laceration in hemodynamically stable patients to avoid unnecessary laparotomies 4

Liver Hematomas

• Subcapsular hematomas should be monitored for expansion, which may indicate ongoing bleeding 3
• Intrahepatic hematomas typically resolve spontaneously but should be followed with imaging to ensure resolution 6
• Large or expanding hematomas may require drainage if they cause mass effect or become infected 1

Management of Complications

• Intrahepatic abscesses should be treated with percutaneous drainage 1
• Delayed hemorrhage without severe hemodynamic compromise may be managed with AG/AE 1
• Hepatic artery pseudoaneurysm should be managed with AG/AE to prevent rupture 1
• Symptomatic or infected bilomas should be managed with percutaneous drainage 1
• For post-traumatic biliary complications not suitable for percutaneous management alone, a combination of percutaneous drainage and endoscopic techniques may be considered 1

Follow-up Care

• Mechanical thromboprophylaxis should be considered in all patients without absolute contraindications 1
• LMWH-based prophylaxis should be started as soon as possible following trauma 1
• Early mobilization should be achieved in stable patients 1
• In the absence of contraindications, enteral feeding should be started as soon as possible 1

Special Considerations

• In patients with concomitant head trauma and/or spinal cord injuries, NOM should be attempted with reliable clinical exam, unless the patient cannot achieve specific hemodynamic goals for the neurotrauma 1, 7
• Specific hemodynamic goals for patients with neurotrauma include SBP > 110 mmHg and/or a CPP between 60-70 mmHg 1, 7
• In low-resource settings, NOM could be considered in patients with hemodynamic stability without evidence of associated injuries, with negative serial physical examinations and negative imaging and blood tests 1