What is the management approach for a patient with a hepatic contusion?

Management of Hepatic Contusion

Non-operative management (NOM) should be the treatment of choice for all hemodynamically stable patients with hepatic contusion, regardless of injury severity, while hemodynamically unstable patients require immediate operative intervention with damage control surgery. 1, 2

Initial Assessment and Diagnostic Approach

The management algorithm is fundamentally determined by hemodynamic status at presentation 1, 2:

For Hemodynamically Stable Patients

• E-FAST should be performed immediately to rapidly detect intra-abdominal free fluid 1
• CT scan with intravenous contrast is mandatory and represents the gold standard for evaluating hepatic contusions in stable patients, with sensitivity and specificity approaching 96-100% 1
• Delayed-phase CT imaging helps differentiate active bleeding from contained vascular injuries 1

For Hemodynamically Unstable Patients

• Diagnostic approach is determined by hemodynamic status; unstable patients proceed directly to operative management without CT imaging 1, 2

Non-Operative Management Protocol

NOM should be attempted for all hemodynamically stable patients with minor (WSES I/AAST I-II), moderate (WSES II/AAST III), and severe (WSES III/AAST IV-V) hepatic contusions in the absence of other injuries requiring surgery. 1, 2

Key Requirements for NOM Success

• Serial clinical evaluations (physical exams and laboratory testing) are mandatory to detect any change in clinical status 1
• ICU admission is required only for moderate (WSES II/AAST III) and severe (WSES III/AAST IV-V) lesions 1
• Angiography with angioembolization (AG/AE) should be considered as first-line intervention in hemodynamically stable patients with arterial blush on CT scan 1, 2

Special Populations

• In pediatric patients, contrast blush on CT is not an absolute indication for AG/AE 1
• For patients with concomitant head trauma or spinal cord injuries, NOM should be attempted with reliable clinical exam, unless specific hemodynamic goals for neurotrauma cannot be achieved (SBP > 110 mmHg and/or CPP 60-70 mmHg) 1, 2

Transient Responders

For patients with moderate or severe injuries who are transient responders, NOM should only be considered in settings with immediate availability of trained surgeons, operating room, continuous ICU monitoring, angiography capability, blood products, and rapid transfer capability to higher-level facilities 1

Operative Management

Hemodynamically unstable and non-responder patients require immediate operative management. 1, 2

Primary Surgical Objectives

• The primary surgical intention is to control hemorrhage and bile leak while initiating damage control resuscitation 1, 2
• For minor bleeding: compression alone, electrocautery, bipolar devices, argon beam coagulation, topical hemostatic agents, simple suture, or omental patching may suffice 2
• For major hemorrhage: manual compression and hepatic packing, ligation of vessels in the wound, hepatic debridement with finger fracture technique, balloon tamponade, or shunting procedures 2

Critical Surgical Principles

• Major hepatic resections should be avoided initially and only considered in subsequent operations for large areas of devitalized liver tissue, performed by experienced surgeons 1, 2
• Angioembolization is useful for persistent arterial bleeding after non-hemostatic or damage control procedures 1, 2
• REBOA may be used in hemodynamically unstable patients as a bridge to definitive hemorrhage control procedures 1, 2

Common Pitfall: The historical approach of formal hepatic resection for severe injuries carries prohibitive mortality; the finger fracture technique with Pringle maneuver and omental packing is the preferred modern approach 3

Management of Complications

Early Complications

• Delayed hemorrhage without severe hemodynamic compromise should be managed with AG/AE 1, 2
• Hepatic artery pseudoaneurysm requires AG/AE to prevent rupture 1, 2

Late Complications

• Intrahepatic abscesses should be treated with percutaneous drainage 1, 2
• Symptomatic or infected bilomas require percutaneous drainage 1, 2
• For post-traumatic biliary complications not suitable for percutaneous management alone, combine percutaneous drainage with endoscopic techniques 1, 2

Supportive Care and Prophylaxis

Thromboprophylaxis

• Mechanical prophylaxis should be considered in all patients without absolute contraindications 1, 2
• LMWH-based prophylaxis should be started as soon as possible following trauma and may be safe in selected patients with liver injury treated with NOM 1, 2

Nutrition and Mobilization

• Enteral feeding should be started as soon as possible in the absence of contraindications 1, 2
• Early mobilization should be achieved in stable patients 1, 2

Resource-Limited Settings

In low-resource settings, NOM could be considered in patients with hemodynamic stability, no evidence of associated injuries, negative serial physical examinations, and negative imaging and blood tests. 1