When should a repeat contrast‑enhanced computed tomography (CT) scan be performed in a patient with hepatic laceration?

When to Repeat CT Scan of Liver Laceration

Routine repeat CT scanning after liver trauma is not recommended; repeat imaging should be reserved exclusively for patients with clinical deterioration, suspected complications, or high-grade injuries (AAST Grade IV-V) during the first 48-72 hours. 1

General Principle: Avoid Routine Repeat Imaging

Do not perform routine follow-up CT scans at arbitrary time intervals (24 or 48 hours) in clinically stable patients with liver lacerations. 1 The consensus across multiple trauma guidelines is clear: routinely repeating CT scanning after trauma or in the follow-up phase is not recommended, and repeat CT should be reserved for cases with evident or suspected complications or significant clinical changes in moderate and severe injuries. 2, 1

• Routine follow-up CT scans have not been shown to alter management decisions in clinically stable patients with Grade III or lower liver injuries. 3, 4
• The practice of routine repeat imaging exposes patients to unnecessary radiation, contrast risks, and costs without improving outcomes. 1, 4

Clinical Monitoring as the Cornerstone

Serial clinical evaluation and hemoglobin measurement represent the cornerstone in evaluating non-operative management (NOM) patients. 2

• Perform serial clinical examinations and hematocrit determination every 6 hours for at least the first 24 hours. 2
• Bedside ultrasound may represent an affordable tool during early follow-up in resource-limited settings. 2
• Clinical examination associated with laboratory and radiological evaluation remains the gold standard for deciding management. 2

Specific Indications for Repeat CT Imaging

High-Grade Injuries (AAST Grade IV-V / WSES Grade III-IV)

Follow-up CT imaging within 48-72 hours is prudent in patients with high-grade liver injuries (AAST Grade IV-V) because these are prone to developing troublesome complications. 1, 5

• High-grade injuries have increased risk of delayed hemorrhage, abscess formation, biloma, and pseudoaneurysm development. 2, 5
• AAST Grade I-III injuries have a low risk of complications and rarely require intervention; routine follow-up CT imaging is not advised for uncomplicated low-grade injuries. 1, 3

Clinical Deterioration or Suspected Complications

Obtain repeat CT scan when any of the following clinical indicators are present: 2, 1, 6

• Abnormal inflammatory response (elevated WBC, CRP, procalcitonin despite treatment) 2, 6
• Persistent or worsening abdominal pain beyond 7 days of observation 2, 6
• Fever developing during NOM 2, 6
• Jaundice suggesting biliary complications 2, 6
• Drop in hemoglobin level indicating possible delayed hemorrhage 2, 1, 6
• Hemodynamic instability or increasing transfusion requirements 2, 7
• Signs of sepsis or systemic inflammatory response 6

Specific Complications Requiring Imaging

Delayed hemorrhage: Occurs in 1.7-5.9% of cases after liver trauma, with mortality rates up to 18%. 2 Repeat CT with arterial phase imaging should be obtained urgently if bleeding is suspected, as contrast extravasation indicates active hemorrhage requiring angioembolization. 2, 5, 7

Biliary complications: Occur in 2.8-30% of cases, including biloma, bile leak, and biliary fistula. 2, 6 Increasing transaminase levels could indicate intrahepatic parenchymal ischemia and warrant repeat imaging. 2

Hepatic artery pseudoaneurysm: Rare (1% prevalence) but requires early identification and angiographic treatment due to high risk of rupture. 2, 5

Abscess formation: Intrahepatic abscesses may develop and require percutaneous drainage. 2

Special Populations

Neurologically impaired or comatose patients: Consider repeat CT in polytrauma patients who cannot provide clinical feedback about deterioration, particularly when they require follow-up imaging for other injuries (e.g., brain CT). 1

Large subcapsular hematomas: While not a strict indication for operative management, these patients have higher risk of NOM failure and should undergo serial blood tests with consideration for repeat imaging if transaminases increase. 2

Postoperative Setting After Laparotomy

Early postoperative CT scan within 24 hours after laparotomy for hepatic trauma identifies clinically relevant ongoing bleeding and should be considered, particularly in blunt injury. 7

• CT scan is 83% sensitive and 75% specific for identifying hepatic bleeding requiring angiography. 7
• Negative CT findings are 96% sensitive and 83% specific for ruling out need for angiography. 7
• Despite occurring in more severely injured patients, early postoperative CT was associated with reduced mortality in multivariate analysis. 7

Critical Pitfalls to Avoid

• Do not delay repeat imaging beyond 24 hours when complications are clinically suspected, as delayed diagnosis increases morbidity and mortality. 2, 1
• Do not rely solely on initial CT in patients who cannot communicate clinical deterioration (comatose, intubated, neurologically impaired patients). 1
• Do not assume ultrasound monitoring alone is sufficient when complications are suspected; CT provides superior anatomical detail. 8
• Do not miss contrast extravasation on arterial phase CT, as this mandates urgent angiography/angioembolization, not continued observation. 8, 7
• Do not perform routine imaging in low-grade injuries (AAST I-III) without clinical indication, as this does not alter management and wastes resources. 1, 3, 4