What is the optimal treatment approach for a patient with a hepatic injury, considering their past medical history and potential complications such as bleeding or infection?

Treatment for Hepatic Injuries

Non-operative management (NOM) should be the treatment of choice for all hemodynamically stable patients with liver injuries of any grade (minor, moderate, or severe) in the absence of other injuries requiring surgery. 1, 2

Initial Diagnostic Approach

The diagnostic strategy is dictated entirely by hemodynamic status 1, 2:

• E-FAST ultrasound is the rapid initial tool for detecting intra-abdominal free fluid in unstable patients 1, 2
• CT scan with intravenous contrast is the gold standard for hemodynamically stable patients and must always be performed before attempting NOM 1, 2

Treatment Algorithm Based on Hemodynamic Status

Hemodynamically Stable Patients (The Majority)

NOM is the standard of care regardless of injury grade (WSES I-III or AAST I-V), with success rates of 85-90% in blunt trauma. 1, 2, 3

Requirements for successful NOM include: 1

• Continuous clinical monitoring with serial physical exams and laboratory testing 1, 2
• ICU admission for moderate (WSES II/AAST III) and severe (WSES III/AAST IV-V) lesions 1, 2
• Immediate availability of CT scan, angiography, operating room, and blood products 1
• Around-the-clock access to trained surgeons 1, 2

Angioembolization (AG/AE) should be considered as first-line intervention in hemodynamically stable patients with arterial blush (contrast extravasation) on CT scan 1, 2. This can reduce transfusion requirements and prevent surgery 1.

Important caveat: In hemodynamically stable children, contrast blush is NOT an absolute indication for angioembolization 1.

Transient Responders

Patients with moderate-to-severe injuries who respond transiently to resuscitation can still be considered for NOM, but only in centers with immediate access to interventional radiology, operating room, ICU monitoring, and blood products 1, 2.

Hemodynamically Unstable Patients (Non-Responders)

These patients require immediate operative management (OM). 1, 2

Primary surgical goals are: 1, 2

• Control hemorrhage and bile leaks
• Initiate damage control resuscitation immediately

Surgical techniques in order of invasiveness: 1, 2

• Simple compression, electrocautery, argon beam coagulation, topical hemostatic agents, or omental patching for minor bleeding 2
• Manual compression and perihepatic packing for major hemorrhage 2
• Portal triad occlusion (Pringle maneuver) with finger fracture technique 2, 4
• Ligation of vessels within the hepatic wound 2
• Hepatic debridement 2

Critical principle: Major hepatic resections should be avoided initially and only considered in subsequent operations for large areas of devitalized tissue, performed by experienced surgeons 1, 2. The mortality for grade IV-V injuries requiring surgery remains high despite advances 3.

Adjunctive measures for persistent bleeding: 1, 2

• Angioembolization after damage control surgery 1, 2
• REBOA (resuscitative endovascular balloon occlusion of the aorta) as a bridge to definitive hemorrhage control 1, 2

Perihepatic packing is effective in 80-82% of cases with ongoing coagulopathy, with planned re-exploration in 24-48 hours 5, 4.

Management of Complications

Complications occur in 12-14% of patients, particularly after high-grade injuries 1:

Bleeding complications:

• Delayed hemorrhage without severe hemodynamic compromise: Manage with angioembolization first 1, 2
• Hepatic artery pseudoaneurysm: Requires angioembolization to prevent rupture, even if asymptomatic 1, 2
• Hemobilia: Typically indicates ruptured intrahepatic pseudoaneurysm; treat with angioembolization 1

Infectious complications:

• Intrahepatic abscesses: Treat with percutaneous drainage (success rate near 100%) 1, 2
• Surgical management only indicated for extensive necrosis affecting patient condition 1

Biliary complications (occur in up to 30% of cases): 1

• Symptomatic or infected bilomas: Percutaneous drainage 1, 2
• Complex biliary complications: Combination of percutaneous drainage and ERCP with stenting 1, 2
• Delayed biliary fistula: Laparoscopic lavage/drainage plus endoscopic stenting as first approach 1, 2

Special Populations

Patients with concomitant head or spinal cord injuries: NOM should be attempted if clinical exam is reliable, unless hemodynamic instability prevents achieving specific neurotrauma goals (SBP >110 mmHg or CPP 60-70 mmHg) 1, 2.

Penetrating trauma: Low-energy stab wounds and gunshot wounds can be managed non-operatively in hemodynamically stable patients without peritonitis 1. High-energy penetrating trauma typically requires operative management 1.

Low-resource settings: NOM can be considered in hemodynamically stable patients with negative serial exams and imaging 1, 2.

Supportive Care During NOM

Thromboprophylaxis: 1, 2

• Mechanical prophylaxis should be used in all patients without absolute contraindications 1, 2
• LMWH should be started as soon as possible, ideally within 48-72 hours to reduce VTE risk fourfold 1, 2
• For patients on anticoagulants, individualize reversal decisions balancing bleeding vs. thrombotic risk 1

Early mobilization should be achieved in stable patients and does not increase NOM failure 1, 2.

Enteral feeding should be started as soon as possible without contraindications 1, 2.

Common Pitfalls to Avoid

• Do not perform major hepatic resections during initial surgery – these carry prohibitive mortality and should only be considered in delayed operations 1, 3
• Do not delay angioembolization in patients with persistent bleeding after damage control surgery 1
• Do not ignore asymptomatic pseudoaneurysms – they require treatment due to high rupture risk 1, 2
• Failure to recognize NOM failure early – grade IV-V injuries have 46.7% NOM failure rate with 50% mortality if surgery is delayed 5