What is the treatment for a subscapular (under the scapula) hematoma of the liver?

Management of Subscapular Hematoma of the Liver

The treatment of subscapular hematoma of the liver should be primarily based on the patient's hemodynamic status, with non-operative management (NOM) as the first-line approach for hemodynamically stable patients. 1

Initial Assessment

• Diagnostic approach must be determined by the patient's hemodynamic status upon presentation 1
• Extended Focused Assessment with Sonography for Trauma (E-FAST) should be performed initially to detect intra-abdominal free fluid 1
• CT scan with intravenous contrast is the gold standard for evaluating liver injuries in hemodynamically stable patients and should always be performed when considering NOM 1

Management Algorithm

For Hemodynamically Stable Patients

• Non-operative management (NOM) is the treatment of choice for all hemodynamically stable patients with subscapular hematoma 2
• Serial clinical evaluations (physical exams and laboratory testing) must be performed to detect changes in clinical status during NOM 2
• Intensive care unit admission is required for moderate and severe lesions 2
• Conservative management includes 3, 4:
  • Close monitoring of hemodynamic parameters
  • Correction of coagulation abnormalities
  • Blood product transfusion as needed
  • Treatment of underlying disorders

For Hemodynamically Unstable Patients

• Hemodynamically unstable and non-responder patients should undergo operative management (OM) 2
• Primary surgical intention should be to control hemorrhage and bile leak while initiating damage control resuscitation 2
• Major hepatic resections should be avoided initially and only considered in subsequent operations for large areas of devitalized liver tissue 2
• Angioembolization is useful for persistent arterial bleeding after non-hemostatic or damage control procedures 2
• Resuscitative endovascular balloon occlusion of the aorta (REBOA) may be used as a bridge to other more definitive procedures for hemorrhage control in critically unstable patients 2

Angiography/Angioembolization (AG/AE)

• May be considered as a first-line intervention in hemodynamically stable patients with arterial blush on CT scan 2
• Useful for management of delayed hemorrhage without severe hemodynamic compromise 2
• Essential for treating hepatic artery pseudoaneurysms to prevent rupture 2

Management of Complications

• Intrahepatic abscesses should be treated with percutaneous drainage 2
• Symptomatic or infected bilomas should be managed with percutaneous drainage 2
• For post-traumatic biliary complications not suitable for percutaneous management alone, a combination of percutaneous drainage and endoscopic techniques may be considered 2
• Laparoscopy as initial approach should be considered in cases of delayed surgery to minimize invasiveness 2

Follow-up Care

• Mechanical thromboprophylaxis should be considered in all patients without absolute contraindications 2
• LMWH-based prophylaxis should be started as soon as possible following trauma 2
• Early mobilization should be achieved in stable patients 2
• In the absence of contraindications, enteral feeding should be started as soon as possible 2

Special Considerations for HELLP Syndrome-Related Subscapular Hematomas

• Subscapular liver hematomas associated with HELLP syndrome can often be managed conservatively if the patient is hemodynamically stable 5
• These patients require intensive multidisciplinary management with close monitoring for potential complications 6
• Conservative management has been successful in up to 84.6% of cases in recent studies 7
• Surgical exploration is reserved for cases with hemodynamic instability or hematoma rupture 4

Pitfalls and Caveats

• Delayed hemorrhage can occur even after initial successful NOM, requiring vigilant monitoring 2
• Patients with concomitant head trauma require special attention to maintain specific hemodynamic goals (SBP > 110 mmHg) to ensure adequate perfusion to both brain and liver 1
• Anticoagulant therapy should be carefully evaluated with individualized risk-benefit assessment 2
• In low-resource settings, NOM could still be considered with close monitoring through serial physical examinations and available imaging/laboratory tests 2