What is the management approach for a liver hematoma?

Management of Liver Hematoma

Management of liver hematoma is determined primarily by hemodynamic status: hemodynamically stable patients should receive non-operative management with serial monitoring, while hemodynamically unstable patients require immediate operative intervention or angioembolization. 1, 2

Initial Diagnostic Approach

Hemodynamic status dictates the diagnostic pathway. 1, 2

• E-FAST ultrasound should be performed immediately in the initial evaluation to rapidly detect intra-abdominal free fluid 1, 2
• CT scan with intravenous contrast is mandatory for all hemodynamically stable patients being considered for non-operative management and represents the gold standard for evaluating liver injuries 1, 2

Management Algorithm

Hemodynamically Stable Patients

Non-operative management (NOM) is the treatment of choice for all hemodynamically stable liver hematomas regardless of injury grade (minor, moderate, or severe), provided no other injuries require surgery. 1, 2

Key Components of Non-Operative Management:

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

Important Caveat:

• In hemodynamically stable children, contrast blush on CT is not an absolute indication for AG/AE 1

Hemodynamically Unstable Patients

Hemodynamically unstable and non-responder patients (WSES IV) require immediate operative management (OM). 1, 2

Surgical Principles:

• Primary surgical goal is hemorrhage control and bile leak management with immediate initiation of 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, vessel ligation in the wound, hepatic debridement and finger fracture, balloon tamponade, or shunting procedures 2
• Major hepatic resections must be avoided initially and only considered in subsequent operations for large areas of devitalized tissue, performed by experienced surgeons 1, 2
• Angioembolization is critical for persistent arterial bleeding after non-hemostatic or damage control procedures 1, 2
• REBOA (resuscitative endovascular balloon occlusion of the aorta) may be used as a bridge to definitive hemorrhage control procedures 1, 2

Transient Responders

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

Management of Complications

Delayed Complications:

• Intrahepatic abscesses: treat with percutaneous drainage 1, 2
• Delayed hemorrhage without severe hemodynamic compromise: manage initially with AG/AE 1, 2
• Hepatic artery pseudoaneurysm: requires AG/AE to prevent rupture 1, 2
• Symptomatic or infected bilomas: manage with percutaneous drainage 1, 2
• Post-traumatic biliary complications: combination of percutaneous drainage and endoscopic techniques (ERCP with stenting) for lesions not suitable for percutaneous management alone 1, 2

Delayed Surgery Considerations:

• Laparoscopy should be considered as the initial approach in delayed surgery to minimize invasiveness and tailor the procedure to the lesion 1
• Interval laparoscopic exploration may be considered as an extension of NOM in a step-up treatment strategy when intra-abdominal injury is suspected days after initial trauma 1

Special Populations

Patients with Concomitant Neurotrauma:

NOM should be attempted in patients with head trauma and/or spinal cord injuries if clinical exam is reliable, unless the patient cannot achieve specific hemodynamic goals (SBP >110 mmHg and/or CPP 60-70 mmHg) for neurotrauma and instability may be due to intra-abdominal bleeding 1, 2

Low-Resource Settings:

NOM can be considered in patients with hemodynamic stability, no associated injuries, negative serial physical examinations, and negative imaging/blood tests 1

Supportive Care and Prophylaxis

• Mechanical thromboprophylaxis is safe and 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
• Anticoagulant reversal requires individualization of the risk-benefit balance in patients taking anticoagulants 1
• Early mobilization should be achieved in stable patients 1, 2
• Enteral feeding should be started as soon as possible in the absence of contraindications 1, 2

Critical Pitfalls to Avoid

Do not perform major hepatic resections during initial surgery—these should only be considered in subsequent operations for devitalized tissue 1, 2. The focus must remain on damage control, not definitive anatomic repair, to minimize mortality in the acute setting.