How should a peri‑hepatic fluid collection following a road‑traffic accident be evaluated and managed?

Management of Perihepatic Fluid Collection Following Road Traffic Accident

In a hemodynamically stable RTA patient with perihepatic collection, obtain contrast-enhanced CT scan immediately to characterize the collection (blood, bile, or abscess), then manage based on clinical symptoms: observe asymptomatic collections, drain symptomatic/infected bilomas or abscesses percutaneously, and use angioembolization for delayed bleeding. 1

Initial Diagnostic Approach

Hemodynamic status determines your entire diagnostic pathway. 1

• Hemodynamically stable patients: Contrast-enhanced CT scan is mandatory and the gold standard for characterizing perihepatic collections 1, 2
• Hemodynamically unstable patients: E-FAST ultrasound for rapid detection of free fluid, then proceed directly to operative management 1
• CT scan will differentiate between hematoma, biloma, or abscess based on fluid density and enhancement patterns 1

Key imaging findings to identify:

• Lenticular-shaped fluid collection compressing liver parenchyma (typical appearance) 3
• Visible tract connecting to intrahepatic lesion (present in >50% of cases) 3
• Arterial contrast blush indicating active bleeding 1
• Central liver laceration suggesting bile leak risk 1

Clinical Monitoring Strategy

Serial clinical evaluations are mandatory—not optional—during non-operative management. 1, 2

Monitor specifically for these complications:

• Dropping hemoglobin (suggests re-bleeding, occurs in 1.7-5.9% with 18% mortality) 1
• Fever and elevated inflammatory markers (suggests abscess formation, 0.6-7% incidence) 1
• Abdominal pain and jaundice (suggests biliary complications, 2.8-30% incidence) 1
• Melena or hematemesis (highly suggestive of ruptured pseudoaneurysm with hemobilia) 1

Routine follow-up CT is NOT necessary unless clinical suspicion of complication arises. 1 Ultrasound is useful for assessing bile leak/biloma in grade IV-V injuries with central lacerations. 1

Management Algorithm by Collection Type

Hematoma (Blood Collection)

Asymptomatic subcapsular hematomas: Conservative management is adequate in the majority of cases 3

• All 10 traumatic hematoma patients in one series survived with conservative management 3
• Mean hospital stay 7.8 days for uncomplicated cases 3

Delayed bleeding/expanding hematoma: Angiography with embolization is first-line treatment 1, 2

• 69% of late bleeding episodes can be treated non-operatively 1
• Angioembolization has high success rates with low complication rates 4

Hepatic artery pseudoaneurysm (1% prevalence): Treat asymptomatic pseudoaneurysms early with angioembolization to prevent rupture, which carries high morbidity 1, 2

Biloma (Bile Collection)

Most traumatic bilomas regress spontaneously without intervention. 1

Symptomatic or infected bilomas: Percutaneous drainage is first-line management 1, 2

• Combine percutaneous drainage with ERCP and biliary stent placement for persistent bile leaks 1
• This combined approach achieves complete symptom resolution 5

Bile peritonitis: Laparoscopic irrigation/drainage combined with endoscopic biliary stenting is preferred over open laparotomy for delayed presentations 1

Abscess (Infected Collection)

CT or ultrasound-guided percutaneous drainage is the treatment of choice with high success rates and no reported mortality. 1, 2

• Abscesses occur in 0.6-7% of cases, typically in severe lesions 1
• Mean hospital stay can extend to 50.7 days in abscess cases 3
• One case report documented Rhodotorula mucilaginosa fungemia in an infected biloma requiring tailored antifungal therapy 6

ICU Admission Criteria

ICU admission is required only for moderate (WSES II/AAST III) and severe (WSES III/AAST IV-V) isolated liver injuries. 1, 2

Essential ICU capabilities must include:

• Immediate availability of trained surgeons and operating room 1, 2
• Access to angiography and angioembolization 1, 2
• Blood and blood products 1
• Continuous hemodynamic monitoring 1, 2

Supportive Care Measures

Thromboprophylaxis: Start mechanical prophylaxis immediately in all patients without contraindication 1, 2

• LMWH-based prophylaxis should begin as soon as possible, ideally within 72 hours (VTE rates increase fourfold when delayed beyond 72 hours) 1
• PE is the third leading cause of death in trauma patients with up to 50% mortality 1

Early mobilization: Achieve early mobilization in stable patients—this does NOT increase NOM failure or secondary bleeding 1, 2

Nutrition: Start enteral feeding as soon as possible within 72 hours unless contraindicated by shock, vasopressor use, or GI bleeding 1, 2

Critical Pitfalls to Avoid

Do not perform routine follow-up CT scans without clinical indication—this exposes patients to unnecessary radiation and cost 1

Do not delay angioembolization for asymptomatic pseudoaneurysms—the rupture risk is high with associated high morbidity 1, 2

Do not rush to surgery for biliary complications—minimally invasive approaches (percutaneous drainage + ERCP) should be attempted first once the patient is stabilized 1

International normalized ratio (INR) is the only laboratory parameter that significantly predicts mortality (1.8 in non-survivors vs 1.4 in survivors, p=0.027), reflecting liver function and coagulation status 3

In low-resource settings without immediate access to angiography, operating room, and blood products, non-operative management should NOT be attempted unless the patient has hemodynamic stability, negative serial exams, and negative imaging 1, 2