Blunt liver injuries in polytrauma: results from a cohort study with the regular use of whole-body helical computed tomography

Novel management of acute or secondary biliary liver conditions using hepatically differentiated human dental pulp cells

The current definitive treatment for acute or chronic liver condition, that is, cirrhosis, is liver transplantation from a limited number of donors, which might cause complications after donation. Hence, bone marrow stem cell transplantation has been developed, but the risk of carcinogenesis remains. We have recently developed a protocol for hepatic differentiation of CD117(+) stem cells from human exfoliated deciduous teeth (SHED). In the present study, we examine whether SHED hepatically differentiated (hd) in vitro could be used to treat acute liver injury (ALI) and secondary biliary cirrhosis. The CD117(+) cell fraction was magnetically separated from SHED and then differentiated into hepatocyte-like cells in vitro. The cells were transplanted into rats with either ALI or induced secondary biliary cirrhosis. Engraftment of human liver cells was determined immunohistochemically and by in situ hybridization. Recovery of liver function was examined by means of histochemical and serological tests. Livers of transplanted animals were strongly positive for human immunohistochemical factors, and in situ hybridization confirmed engraftment of human hepatocytes. The tests for recovery of liver function confirmed the presence of human hepatic markers in the animals' blood serum and lack of fibrosis and functional integration of transplanted human cells into livers. No evidence of malignancy was found. We show that in vitro hdSHED engraft morphologically and functionally into the livers of rats having acute injury or secondary biliary cirrhosis. SHED are readily accessible adult stem cells, capable of proliferating in large numbers before differentiating in vitro. This makes SHED an appropriate and safe stem cell source for regenerative medicine.

Hepatic trauma: a 21-year experience

OBJECTIVE

To evaluate the epidemiological aspects, behavior, morbidity and treatment outcomes for liver trauma.

METHODS

We conducted a retrospective study of patients over 13 years of age admitted to a university hospital from 1990 to 2010, submitted to surgery or nonoperative management (NOM).

RESULTS

748 patients were admitted with liver trauma. The most common mechanism of injury was penetrating trauma (461 cases, 61.6%), blunt trauma occurring in 287 patients (38.4%). According to the degree of liver injury (AAST-OIS) in blunt trauma we predominantly observed Grades I and II and in penetrating trauma, Grade III. NOM was performed in 25.7% of patients with blunt injury. As for surgical procedures, suturing was performed more frequently (41.2%). The liver-related morbidity was 16.7%. The survival rate for patients with liver trauma was 73.5% for blunt and 84.2% for penetrating trauma. Mortality in complex trauma was 45.9%.

CONCLUSION

trauma remains more common in younger populations and in males. There was a reduction of penetrating liver trauma. NOM proved safe and effective, and often has been used to treat patients with penetrating liver trauma. Morbidity was high and mortality was higher in victims of blunt trauma and complex liver injuries.

Pre-hospital and early in-hospital management of severe injuries: changes and trends

The pre-hospital and early in-hospital management of most severely injured patients has dramatically changed over the last 20 years. In this context, the factor time has gained more and more attention, particularly in German-speaking countries. While the management in the early 1990s aimed at comprehensive and complete therapy at the accident site, the premise today is to stabilise trauma patients at the accident site and transfer them into the hospital rapidly. In addition, the introduction of training and education programmes such as Pre-hospital Trauma Life Support (PHTLS(®)), Advanced Trauma Life Support (ATLS(®)) concept or the TEAM(®) concept has increased the quality of treatment of most severely injured trauma patients both in the preclinical field and in the emergency trauma room. Today, all emergency surgical procedures in severely injured patients are generally performed in accordance with the Damage Control Orthopaedics (DCO) principle. The advancements described in this article provide examples for the improved quality of the management of severely injured patients in the preclinical field and during the initial in-hospital treatment phase. The implementation of trauma networks, the release of the S3 polytrauma guidelines, and the DGU "Weißbuch" have contributed to a more structured management of most severely injured patients.

Imaging in abdominal trauma

Abdominal trauma is increasing and although penetrating wounds are also on the increase, blunt trauma remains more common. The cornerstone of management is accurate diagnosis and the advent of high-quality rapid CT scanning has revolutionised the treatment of serious abdominal injury. It has allowed the introduction of selective non-operative management which is applicable to many low- and intermediate-grade injuries, whereas application of interventional radiology can avert laparotomy in higher grade injuries. This review examines the pathophysiology of the commonest forms of abdominal injury and uses a series of cases to illustrate the impact of modern radiology in management.

Conservative management of major liver necrosis after angioembolization in a patient with blunt trauma

Management of liver injury is challenging particularly for the advanced grades. Increased utility of nonoperative management strategies increases the risk of developing massive liver necrosis (MLN). We reported a case of a 19-year-old male who presented with a history of motor vehicle crash. Abdominal computerized tomography (CT) scan revealed large liver laceration (Grade 4) with blush and moderate free hemoperitoneum in 3 quadrants. Patient was managed nonoperatively by angioembolization. Two anomalies in hepatic arteries origin were reported and both vessels were selectively cannulated and bilateral gel foam embolization was achieved successfully. The patient developed MLN which was successfully treated conservatively. The follow-up CT showed progressive resolution of necrotic areas with fluid replacement and showed remarkable regeneration of liver tissues. We assume that patients with high-grade liver injuries could be managed successfully with a carefully designed protocol. Special attention should be given to the potential major associated complications. A tailored multidisciplinary approach to manage the subsequent complications would represent the best recommended strategy for favorable outcomes.

Endovascular interventions for traumatic portal venous hemorrhage complicated by portal hypertension

Life-threatening hemorrhage rarely occurs from the portal vein following blunt hepatic trauma. Traditionally, severe portal bleeding in this setting has been controlled by surgical techniques such as packing, ligation, and venorrhaphy. The presence of portal hypertension could potentially increase the amount of hemorrhage in the setting of blunt portal vein trauma making it more difficult to control. This case series describes the use of indirect carbon dioxide portography to identify portal hemorrhage. Furthermore, these cases illustrate attempted endovascular treatment utilizing a transjugular intrahepatic portosystemic shunt in one scenario and transmesocaval shunt coiling of a jejunal varix in the other.

Effect of Strain Rate on the Material Properties of Human Liver Parenchyma in Unconfined Compression

The liver is one of the most frequently injured organs in abdominal trauma. Although motor vehicle collisions are the most common cause of liver injuries, current anthropomorphic test devices are not equipped to predict the risk of sustaining abdominal organ injuries. Consequently, researchers rely on finite element models to assess the potential risk of injury to abdominal organs such as the liver. These models must be validated based on appropriate biomechanical data in order to accurately assess injury risk. This study presents a total of 36 uniaxial unconfined compression tests performed on fresh human liver parenchyma within 48 h of death. Each specimen was tested once to failure at one of four loading rates (0.012, 0.106, 1.036, and 10.708 s−1) in order to investigate the effects of loading rate on the compressive failure properties of human liver parenchyma. The results of this study showed that the response of human liver parenchyma is both nonlinear and rate dependent. Specifically, failure stress significantly increased with increased loading rate, while failure strain significantly decreased with increased loading rate. The failure stress and failure strain for all liver parenchyma specimens ranged from −38.9 kPa to −145.9 kPa and from −0.48 strain to −1.15 strain, respectively. Overall, this study provides novel biomechanical data that can be used in the development of rate dependent material models and the identification of tissue-level tolerance values, which are critical to the validation of finite element models used to assess injury risk.

Liver injury following blunt abdominal trauma: a new mechanism-driven classification

Purposes

The current classifications for blunt liver trauma focus only on the extent of liver injury. However, these scores are independent from the localization of liver injury and mechanism of trauma.

Methods

The type of liver injury after blunt abdominal trauma was newly classified as type A when it was along the falciform ligament with involvement of segments IVa/b, III, or II, and type B when there was involvement of segments V–VIII. With the use of a prospectively established database, the clinical, perioperative, and outcome data were analyzed regarding the trauma mechanism, as well as the radiological and intraoperative findings.

Results

In 64 patients, the type of liver injury following blunt abdominal trauma was clearly linked with the mechanism of trauma: type A injuries (n = 28) were associated with a frontal trauma, whereas type B injuries (n = 36) were found after complex trauma mechanisms. The demographic data, mortality, ICU stay, and hospital stay showed no significant differences between the two groups. Interestingly, all patients with type A ruptures required immediate surgical intervention, whereas six patients (16.7 %) with type B ruptures could be managed conservatively.

Conclusions

This new classification for blunt traumatic hepatic injury is based on the localization of parenchymal disruption and correlates with the mechanism of trauma. The type of liver injury correlated with the necessity for surgical therapy.

[Emergency trauma room management in severely and most severely injured patients. A multidisciplinary task]

The treatment of most severely injured patients represents a great challenge for the trauma room team. Besides the time factor, which is a crucial cornerstone of the treatment in general and of the appropriate treatment of life-threatening injuries in particular, minor injuries and non-life-threatening injuries must also be taken into account. For this task, multidisciplinary processes play a paramount role. Advanced Trauma Life Support®, Definitive Surgical Trauma Care and the European Trauma Course represent training concepts, which predefine structured diagnostic and treatment procedures. These concepts allocate the highest treatment priority to injuries that may be immediately fatal for the patient. Besides those life-threatening injuries that are commonly summarised under the term "deathly six", other minor traumas should also be assessed and treated in a structured manner as they may often considerably affect the quality of life after trauma.

Influences on the amount of intraperitoneal haemorrhage after blunt liver injury: a retrospective autopsy study

OBJECTIVE

The amount of intraperitoneal blood loss due to traumatic liver injury is rarely addressed in correlation with concomitant injuries or pre-existing liver disease.

METHODS

We carried out a retrospective review of autopsy reports from 1995 until 2007 at the Institute of Forensic Medicine (Bern, Switzerland), and evaluated 126 cases of blunt liver trauma for the amount of blood in the abdominal cavity, severity of liver injury, pre-existing liver disease and concomitant injuries.

RESULTS

Grades IV and V liver injuries (American Association for the Surgery of Trauma classification) showed greater blood loss than grades I and II liver injuries. Grade III liver injuries showed no significant difference in the amount of intraperitoneal blood compared with grades IV and V liver injuries and 53 cases of liver injuries (42%) did not bleed at all. The amount of blood found in the abdominal cavity ranged from 0 to 4500 ml. Pre-existing liver steatosis showed no significant difference in injury pattern or bleeding from the liver. Three cases with liver haemangiomas and one with a liver cyst showed no lesion to their focal alteration. Because of the small number of cases, no statistical analysis was made concerning concomitant injuries such as head, thoracic or limb trauma.

CONCLUSION

Higher grades of liver injury severity are associated with higher blood loss into the abdominal cavity. In addition, a patient with pre-existing liver steatosis seems not to be at any greater risk of having a larger rupture or having stronger bleeding from the liver after a blunt impact compared with a patient with a normal liver.

Non-operative management of liver trauma

The liver is one of the commonest intra-abdominal organs injured worldwide in blunt and penetrating trauma and its management has evolved significantly in the last 30 years. Mandatory laparotomy has been replaced by an acceptance that for most blunt hepatic trauma, a selective non-operative approach is safe and effective with a failure rate ie the need to proceed to delayed laparotomy of approximately 10%. There is a markedly lower rate of complications in those that are managed non-operatively. Adjuncts to this conservative regimen such as angioembolisation and delayed laparoscopy to treat biliary peritonitis increase the chances of avoiding laparotomy. This belief in non-operative management has also been transferred to some degree to penetrating liver trauma, where there is a gradual accumulation of evidence to support this non-operative approach in a carefully selected group of patients. This article examines the evidence supporting the selective non-operative management of both blunt and penetrating liver trauma and describes the outcomes and complications.

[S3 guideline on treatment of polytrauma/severe injuries. Trauma room care]

For the multidisciplinary treatment team, the medical care of the most severely injured patients in the trauma room means they have to convert a structured evaluation process into a target-oriented treatment process. Apart from the time factor and the detection of life-threatening injuries that are often summarised under the term"deadly six", also so-called trivial injuries should not be overlooked, because they occasionally can crucially affect the quality of life after trauma. The S3 guideline on polytrauma does not claim to be complete. Important subjects such as the medical care of children have not yet been integrated into the guideline, but it is planned to include them in the next revision.

Imaging of acute conditions affecting the hepatic vasculature

Liver imaging primarily consists of evaluating the parenchyma and biliary system. However, the liver has a rich, complex vascularity which can also be affected by numerous disease processes. By considering disease processes that primarily affect the hepatic veins, portal veins, and hepatic arteries, an anatomy-based approach of hepatic vascular diseases can be applied to image interpretation to allow rapid diagnosis and prompt initiation of treatment. Computed tomography, magnetic resonance imaging, and ultrasound are all effectively used to evaluate the liver and can play complimentary roles. In this article, the key imaging findings of acute conditions affecting the hepatic veins (passive congestion, acute thrombosis/Budd-Chiari, stenosis), portal veins (thrombosis, phlebitis, stenosis), hepatic arteries (laceration, pseudoaneurysm, thrombosis), and arteriovenous structures (hereditary hemorrhagic telangiectasis, arteriovenous fistula) will be reviewed.

Efficacy and safety of non-operative management of blunt liver trauma

BACKGROUND

The liver is the most frequently affected organ during blunt abdominal trauma. Blunt liver trauma management has changed in the last two decades with the introduction of the computed tomography (CT) scan and non-operative management of stable patients.

OBJECTIVE

To determine the incidence, efficacy, and failure rate of blunt liver trauma non-operative management as well as the risk factors associated with such treatment in a level 1 trauma center in Colombia.

METHODS

We conducted an observational descriptive study on patients with blunt liver trauma who were admitted to a level 1 trauma center in Colombia. The evaluated outcomes were indications of immediate surgical treatment and the success of non-operative management.

RESULTS

A total of 73 patients were studied. The most common mechanism of trauma continues to be motor vehicle crashes. In 14 patients (19.2%), immediate surgical intervention was necessary and we observed a Revised Trauma Score (RTS) above 7.8 and intra-abdominal injuries as risk factors. Three patients died (21.4%). Fifty-nine patients (80.8%) received non-operative management, which failed in seven patients (11.2%). Age, severity of liver injury, and intra-abdominal injuries were not risk factors in the failure of non-operative management. Mortality in the non-operative management group was 1.7%.

CONCLUSION

Non-operative management is the treatment of choice for polytraumatized patients with blunt liver trauma who are hemodynamically stable. Non-operative management is an effective and safe treatment strategy. However, patients with an RTS score under 7.8 and other intra-abdominal non-liver injuries are at increased risk for an immediate surgical intervention.

Protective effect of ligustrazine on residual liver tissue in rats after hepatectomy

AIM: To investigate the effect of ligustrazine in alleviating inflammation and inhibiting the activation of NF-κB in rats after liver trauma.

METHODS: Sixty rats which underwent 2/3 hepatectomy were randomly and equally divided into three groups. Group A was intraperitoneally injected with normal saline, and groups B and C were injected with PDTC and ligustrazine, respectively. The general status of the rats was observed, and changes in serum levels of aminotransferases were measured. Hepatic pathological changes were examined, and the activation of NF-κB was investigated by Western blot.

RESULTS: Cellular swelling was milder in group C than in group A. Serum levels of ALT at 6 and 10 h after the operation were significantly lower in group C than in group A (6 h: 488.9 U/L ± 59.2 U/L vs 651.6 ± 65.3 U/L; 10 h: 670.0 U/L ± 73.4 U/L vs 930.0 U/L ± 62.9 U/L; both P < 0.05). Serum levels of AST at 6 and 10 h were also significantly lower in group C than in group A (6 h: 1113.1 U/L ± 138.7 U/L vs 1315.0 U/L ± 111.0 U/L; 10 h: 1388.2 U/L ± 209.6 U/L vs 1728.4 U/L ± 87.3 U/L; both P < 0.05). The levels of activated NF-κB in group C (0.78 ± 0.04, 0.75 ± 0.07) were lower than those in group A (both were 1), higher than those in group B (0.68 ± 0.09, 0.66 ± 0.04) at 2 and 10 h (all P < 0.05), but were comparable to that in group B at 6 h (0.71 ± 0.07 vs 0.64 ± 0.09, P > 0.05).

CONCLUSION: Ligustrazine protects the posttraumatic liver tissue possibly by inhibiting the activation of NF-κB.

Iatrogenic liver trauma managed with mesh-wrapping and ligation of portal vein branch: A case report

INTRODUCTION

Liver trauma is a critical condition that requires swift multidisciplinary approach. In complex hepatic injuries perihepatic packing is an established life-saving procedure. The aim of this study is to evaluate and highlight the value of absorbable mesh wrapping of the injured liver, combined with ipsilateral ligation of portal vein branch.

CASE PRESENTATION

An 82-year-old patient underwent an open cholocystectomy, for gallbladder empyema. The second postoperative day he was re-operated on due to active hemorrhage. The bleeding was controlled by suturing the bed of the gallbladder fossa. During this maneuver a portal vein branch was torn resulting in a rapidly expanding subcapsular liver hematoma which led to the formation of two deep lacerations on the liver parenchyma. This life-threatening condition was treated by wrapping an absorbable mesh around the right liver lobe and subsequently ligating the right portal vein branch extrahepaticaly.

CONCLUSION

Mesh wrapping of the fragmented liver with absorbable mesh constitutes a safe and effective method, in treating grade IV and V liver injuries, especially when combined with ipsilateral ligation of the bleeding vessel.

Hepatic and splenic trauma

The spleen and liver are two organs commonly injured in various forms of abdominal trauma. Their relative size, relatively fixed positions, and abundant vascular supply make them prone both to injury and potential sources of catastrophic haemorrhage. With the evolution of computed tomography (CT), there has been a paradigm shift in the management of such injuries from operative to non-operative means. Advances in imaging techniques have also enabled clinicians to observe such patients for development of complications, and when appropriate, utilise the repertoire of interventional radiology techniques available. This review aims to summarise the epidemiology of splenic and hepatic trauma, the mechanisms of trauma and the classifications used in describing these injuries. The role of commonly used imaging modalities, namely ultrasound and CT, both in the acute setting and in observation of these patients for delayed complications is described, and finally a brief description of the current management strategies of such injuries is given.

Low-dose MDCT findings of blunt hepatobiliary trauma

This pictorial essay shows low-dose multi-detector computed tomography (MDCT) findings of blunt hepatobiliary trauma, and describes the indications and protocol for MDCT. Given the universal usage of MDCT in assessing the liver in blunt abdominal trauma, reduction of patient dose is essential. The new l0se MDCT protocol presented here can achieve up to 50% dose reduction while maintaining diagnostic image quality and thus facilitate dose sensitive patient management. Our institution's blunt hepatobiliary MDCT imaging algorithm can help determine which patients require operative therapy. Injury to the liver is graded on various schemes, one being the Organ Injury Scale devised by the American Association for the Surgery of Trauma classification based on the extension of the lesion and bleeding.

Management of liver trauma in adults

The liver is one of the most commonly injured organs in abdominal trauma. Recent advancements in imaging studies and enhanced critical care monitoring strategies have shifted the paradigm for the management of liver injuries. Nonoperative management of both low- and high-grade injuries can be successful in hemodynamically stable patients. Direct suture ligation of bleeding parenchymal vessels, total vascular isolation with repair of venous injuries, and the advent of damage control surgery have all improved outcomes in the hemodynamically unstable patient population. Anatomical resection of the liver and use of atriocaval shunt are rarely indicated.

Resuscitation of uncontrolled traumatic hemorrhage induced by severe liver injury: the use of human adrenomedullin and adrenomedullin binding protein-1

BACKGROUND

The liver is a major organ that is susceptible to injury after blunt or penetrating trauma to the abdomen. No specific nonoperative treatment exists for traumatic hepatic injury (THI). Adrenomedullin (AM), a vasoactive peptide, combined with its binding protein, AM protein (AMBP-1), is beneficial in various disease conditions. In this study, we propose to analyze whether human AM combined with human AMBP-1 provides benefit in a model of THI in the rat.

METHODS

Male adult rats were subjected to trauma hemorrhage by resection of ∼50% of total liver tissues and allowed bleeding for 15 minutes. Immediately thereafter, human AM (48 μg/kg birth weight) plus human AMBP-1 (160 μg/kg birth weight) were given intravenously over 30 minutes in 1-mL normal saline. After 4 hours, the rats were killed, blood was collected, and tissue injury indicators were assessed. A 10-day survival study was also conducted.

RESULTS

At 4 hours after THI, plasma AMBP-1 levels were markedly decreased. Plasma levels of liver injury indicators (i.e., aspartate aminotransferase, alanine aminotransferase, and lactate dehydrogenase) were significantly increased after THI. Similarly, lactate, creatinine, and tumor necrosis factor-α levels were significantly increased after THI. Administration of human AM/AMBP-1 after THI produced significant decreases of 64%, 23%, and 19% of plasma aspartate aminotransferase, alanine aminotransferase, and lactate dehydrogenase levels, respectively. Similarly, plasma levels of lactate, creatinine, and tumor necrosis factor-α were also decreased by 42%, 28%, and 46% after human AM/AMBP-1 treatment, respectively. In a 10-day survival study, although vehicle treatment produced 41% survival, human AM/AMBP-1 treatment improved the survival rate to 81%.

CONCLUSIONS

Administration of human AM/AMBP-1 significantly attenuated tissue injury and inflammation and improved survival after THI. Thus, human AM/AMBP-1 can be developed as a novel treatment for victims with uncontrolled traumatic hemorrhage.

Hemobilia

Hemobilia is an uncommon medical problem that presents in a varied fashion and is increasingly of iatrogenic origin. The diagnosis of hemobilia needs to be considered in patients presenting with upper gastrointestinal bleeding, particularly if they are jaundiced with abdominal pain in the setting of recent or previous percutaneous liver intervention or abdominal trauma. Multislice computed tomographic angiography is increasingly being used in the investigation, but transcatheter arterial embolization remains the cornerstone of managing those patients requiring intervention. The majority of patients with hemobilia will be managed supportively or with radiologic intervention; most do not require surgical intervention.

Management of liver trauma

BACKGROUND

Blunt and penetrating liver trauma is common and often presents major diagnostic and management problems.

METHODS

A literature review was undertaken to determine the current consensus on investigation and management strategies.

RESULTS

The liver is the most frequently injured organ following abdominal trauma. Immediate assessment with ultrasound has replaced diagnostic peritoneal lavage in the resuscitation room, but computerised tomography remains the gold standard investigation. Nonoperative management is preferred in stable patients but laparotomy is indicated in unstable patients. Damage control techniques such as perihepatic packing, hepatotomy plus direct suture, and resectional debridement are recommended. Major complex surgical procedures such as anatomical resection or atriocaval shunting are now thought to be redundant in the emergency setting. Packing is also recommended for the inexperienced surgeon to allow control and stabilisation prior to transfer to a tertiary centre. Interventional radiological techniques are becoming more widely used, particularly in patients who are being managed nonoperatively or have been stabilised by perihepatic packing.

CONCLUSIONS

Management of liver injuries has evolved significantly throughout the last two decades. In the absence of other abdominal injuries, operative management can usually be avoided. Patients with more complex injuries or subsequent complications should be transferred to a specialist centre to optimise final outcome.

Management of liver trauma

BACKGROUND

Blunt and penetrating liver trauma is common and often presents major diagnostic and management problems.

METHODS

A literature review was undertaken to determine the current consensus on investigation and management strategies.

RESULTS

The liver is the most frequently injured organ following abdominal trauma. Immediate assessment with ultrasound has replaced diagnostic peritoneal lavage in the resuscitation room, but computerised tomography remains the gold standard investigation. Nonoperative management is preferred in stable patients but laparotomy is indicated in unstable patients. Damage control techniques such as perihepatic packing, hepatotomy plus direct suture, and resectional debridement are recommended. Major complex surgical procedures such as anatomical resection or atriocaval shunting are now thought to be redundant in the emergency setting. Packing is also recommended for the inexperienced surgeon to allow control and stabilisation prior to transfer to a tertiary centre. Interventional radiological techniques are becoming more widely used, particularly in patients who are being managed nonoperatively or have been stabilised by perihepatic packing.

CONCLUSIONS

Management of liver injuries has evolved significantly throughout the last two decades. In the absence of other abdominal injuries, operative management can usually be avoided. Patients with more complex injuries or subsequent complications should be transferred to a specialist centre to optimise final outcome.

MR imaging in gastrointestinal emergencies

Accurate and rapid diagnostic imaging is essential for the appropriate management of acute gastrointestinal conditions. Computed tomography (CT) is the modality most often used in this setting because of its widespread availability and the relative speed, ease, and uniformity with which evaluations can be performed. CT allows the diagnosis of a wide spectrum of acute gastrointestinal diseases with the adjustment of only a few variables in the acquisition protocol. For example, the contrast material volume, injection rate, and delay before image acquisition can be manipulated to enhance vascular or organ-specific contrast for myriad gastrointestinal diagnoses. Magnetic resonance (MR) imaging has similarly robust potential, although its integration into the acute care setting requires greater technical and logistical effort. Improved MR imaging sequences, advances in coil technology, streamlined imaging protocols, and increased technical and professional familiarity with the modality make it an increasingly attractive option when there is concern about patient radiation exposure or allergy to iodinated contrast material. A variety of acute abdominal conditions, including pancreatic and biliary tract trauma, choledocholithiasis, gallbladder disease, acute pancreatitis, and appendicitis can be rapidly and accurately demonstrated with MR imaging. MR imaging also can play a vital role in the follow-up assessment of treatment response and in the diagnosis of indeterminate findings at CT or ultrasonography. Nevertheless, incompatibility of patient monitoring devices with the MR magnet, lack of MR imaging system availability, and the acuity of illness may limit the use of the modality.

The definition of polytrauma: the need for international consensus

INTRODUCTION

Polytrauma patients represent the ultimate challenge to trauma care and the optimisation of their care is a major focus of clinical and basic science research. A universally accepted definition for polytrauma is vital for comparing datasets and conducting multicentre trials. The purpose of this review is to identify and evaluate the published definitions of the term "polytrauma".

MATERIALS AND METHODS

A literature search was conducted for the time period January 1950-August 2008. The Medline, Embase and Cochrane Library databases were searched using the keyword "polytrauma". Articles were evaluated without language exclusion for the occurrence of the word "polytrauma" in the text and the presence of a subsequent definition. Relevant online resources and medical dictionaries were also reviewed.

RESULTS

A total of 1,665 publications used the term polytrauma, 47 of which included a definition of the term. The available definitions can be divided into eight groups according to the crux of the definition. No uniformly used consensus definition exists. None of the existing definitions were found to be validated or supported by evidence higher than Level 4.

CONCLUSION

This review identified the lack of a validated or consensus definition of the term polytrauma. The international trauma community should consider establishing a consensus definition for polytrauma, which could be validated prospectively and serve as a basis for future research.

Primary pan-computed tomography for blunt multiple trauma: can the whole be better than its parts?

Single-pass, whole-body computed tomography (pan-CT) was proposed in the late 1990s as a new concept for the diagnostic work-up of severely injured patients. Since its introduction, it has led to considerable debate among clinicians and scientists, triggered by concerns about its immediate safety, questionable therapeutic advantages and exposure to radiation. However, it was recently shown that pan-CT scanning may be associated with a reduction in trauma mortality. In this article, we provide an overview of current knowledge of the value of this compelling concept. The diagnostic accuracy of multidetector row CT (MDCT) for clearing various anatomical regions in trauma patients is, at best, unclear. Little is known about the accuracy of pan-CT as a whole, which weakens statements about its effectiveness and prevents inferences about survival advantages. This last point may be explained by a stage-migration or "Will Rogers" phenomenon: Pan-CT increases injury severity by detecting lesions that would not have been recognized by conventional methods but still do not affect treatment decisions, thus artificially lowering the ratio of observed to expected deaths. In order to maintain the credibility of pan-CT technology for trauma, a rigorous, large-scale evaluation of its accuracy is required. Such an evaluation requires consensus about the definition of true and false positive and negative findings in the setting of blunt multiple trauma. In addition, triage criteria need to be refined to increase specificity and reduce the number of unnecessary scans.

A multicenter review of deep venous thrombosis prophylaxis practice patterns for blunt hepatic trauma

BACKGROUND

Non-operative management of blunt hepatic trauma is successful in the majority of hemodynamically stable patients. Due to the risk of recurrent hemorrhage, pharmacologic deep venous thrombosis (DVT) prophylaxis is often delayed. The optimal timing of prophylaxis is unclear. A multi-centre, retrospective review of patients with blunt hepatic injuries presenting between 2000 and 2004 was performed. All patients had an ISS >/= 12 and a CT scan confirming hepatic trauma. Patients were categorized into: (1) early DVT prophylaxis (</= 48 hrs of admission), (2) delayed prophylaxis (>48 hrs), and (3) no prophylaxis.

METHODS AND RESULTS

Thirty-seven (25%) and 45 (42%) patients received early and delayed DVT prophylaxis respectively. The remainder (32%) received none. Mean hepatic injury grades were lower in the early prophylaxis group (II) compared to the delayed and no prophylaxis cohorts (III)(p = 0.002). The number of patients requiring post-admission blood transfusions was highest in the delayed group (44%) compared to the early (26%) and no prophylaxis (6%) groups (p = 0.03). No patient in the early prophylaxis cohort developed a DVT or required delayed angiographic or operative intervention. Two patients in the delayed group failed non-operative management. Eight (18%) patients in the delayed group developed a clinically significant DVT; 1 (2%) progressed to a PE.

CONCLUSION

Practice patterns indicate that chemical DVT prophylaxis initiated within 48 hours of admission may be safe in patients with significant blunt hepatic trauma. Delays in prevention result in venothromboembolic events, but not in fewer blood transfusions or a decreased need for subsequent angiographic or operative therapies.

Hemobilia as a late complication after blunt abdominal trauma: a case report and review of the literature

BACKGROUND

Bleeding within the biliary tree, called hemobilia, is a rare complication after blunt hepatic trauma.

OBJECTIVES

To report on a patient who developed hemobilia 1 month after a blunt abdominal injury and to discuss the diagnosis and treatment of hemobilia.

CASE REPORT

A 17-year-old boy presented with upper gastrointestinal bleeding caused by hemobilia 1 month after a blunt liver injury. Angiography revealed a pseudoaneurysm of the right hepatic artery, which was successfully treated with embolization.

CONCLUSIONS

The diagnosis of hemobilia first requires consideration of the diagnosis, particularly in patients with previous abdominal trauma. Hemobilia should be included in the differential diagnosis of upper gastrointestinal bleeding. Investigations of choice include computed tomography scan followed by angiography. During angiography, treatment can be done by endovascular embolization.

[Significance of liver trauma for the incidence of sepsis, multiple organ failure and lethality of severely injured patients. An organ-specific evaluation of 24,771 patients from the trauma register of the DGU]

BACKGROUND

The prognosis of multiple injured patients is mainly limited by initial severe hemorrhage causing hemorrhagic shock, subsequent sepsis and multiple organ failure (MOF). Although mechanisms of altered microcirculation, cytokine release etc. have been intensively investigated, little is known about the relevance of severe liver trauma as an independent predictive outcome factor in these patients. This study aimed to clarify the impact of severe liver trauma in one of the largest trauma databases.

PATIENTS AND METHODS

The study was based on data from the German trauma register within the German Society for Trauma Surgery (DGU) and 24,711 patients from 113 hospitals were collected for retrospective analysis between 1993 and 2005. Patients with an injury severity score (ISS) >16, no isolated head injury and primary admission to a trauma center were included. Data were allocated according to the injury pattern into I liver group (severe damage of the liver, AIS>3 and AIS abdomen <3), II Abdomen group (severe abdominal trauma AIS>3, AIS liver <3) and III Control group (liver and/or abdominal trauma AIS<3, other trauma AIS>3).

RESULTS

Out of 24,771 multiple injured patients from 113 trauma centers, 321 individuals were identified which matched the criteria of the liver group. Another 574 patients were allocated to the abdomen group while the majority of patients formed the trauma group (9574). Severe injury of the liver is associated with excessive demands for volume resuscitation and induces a significantly increased risk for sepsis and MOF compared to both other groups (sepsis 19.9% vs 11%; MOF 32.7% vs 16.6%). Furthermore, deleterious outcome is more frequent associated with patients with severe liver trauma (lethality 34.9%) compared to severe abdominal trauma (12%) and the control group (19.5%).

CONCLUSIONS

Severe liver trauma is an independent predictor for severe hemorrhage with a substantial increased risk of sepsis, MOF and trauma-related death. While conservative treatment of patients with severe liver trauma but no hemorrhage is effective, patients with hemodynamic instability seem to form a subgroup where contemporary treatment modalities are not yet sufficient.

Trauma hepático: epidemiologia de cinco anos em um serviço de emergência

OBJETIVO: analisar características epidemiológicas relacionadas ao trauma hepático e fazer breve revisão das modalidades diagnósticas e de tratamento. MÉTODO: estudo retrospectivo de fevereiro/2002 a maio/2007 através de prontuários de 154 pacientes admitidos com trauma hepático no Hospital Universitário Cajuru (HUC). RESULTADOS: Foram encontrados 90,26% das vítimas de trauma hepático do sexo masculino e a média de idade de 26,28 anos. Quanto ao mecanismo de trauma, 72,73% foram por trauma penetrante, sendo que destes, 55,84% foram por arma de fogo e 16,88% por arma branca; e 27,27% por trauma contuso, no qual 73,81% envolveram colisões por veículos automotores e 26,49% outros. Na admissão o período de 0h - 12h foi o de maior prevalência, a média da pressão arterial foi de 117,6/72,3 mmHg, da freqüência cardíaca de 99,03 bpm e do Glasgow de 13,6. O tempo decorrido entre a admissão e a realização da primeira cirurgia foi de menos de 2 horas em 60,43%. Verificou-se maior incidência da lesão Grau II, seguida da Grau III e IV (totalizando 88,3%). As lesões cirúrgicas associadas foram encontradas em mais de 75% dos casos. O ISS médio foi de 15,09, 19,85, 27,83, 35,47 e 40,93 e a sobrevida de 100%, 88,88%, 81,25%, 48,48% e 22,23% nas lesões grau I, II, III, IV e V, respectivamente. CONCLUSÃO: os dados epidemiológicos encontrados neste estudo refletem a violência na sociedade moderna, que se traduz com aumento da complexidade das lesões encontradas e constitui desafio para decisão da melhor conduta terapêutica.

Vascular emergencies in liver trauma

The use of CT in the diagnosis and management of liver trauma is responsible for the shift from routine surgical versus non-surgical treatment in the management of traumatic liver injuries, even when they are of high grade. The main cause of complication and of death in liver trauma is related to vascular injury. The goal of this review focussed on the vascular complications of liver trauma is to describe the elementary lesions shown by CT in liver trauma including laceration, parenchymal hematoma and contusions, partial devascularisation, subcapsular hematomas, hemoperitoneum, active bleeding, pseudoaneurysm of the hepatic artery, bile leak, and periportal oedema, to illustrate the possible pitfalls in CT diagnosis of liver trauma and to underline the key-points which may absolutely be present in a CT report of liver trauma. Then we will remind the grading system based on the CT features and we will analyze the interest and limitations of such grading systems. Last we will discuss the diagnostic strategy at the early phase in patients with suspected liver trauma according to their clinical conditions and underline the conditions of arterial embolization, and then we will discuss the diagnosis strategy at the delayed phase according to the suspected complications.

A novel multiple-trauma CT-scanning protocol using patient repositioning

Emergency CT examination is considered to be a trade-off between a short scan time and the acceptance of artifacts. This study evaluates the influence of patient repositioning on artifacts and scan time. Eighty-three consecutive multiple-trauma patients were included in this prospective study. Patients were examined without repositioning (group 1, n=39) or with patient rotation to feet-first with arms raised for scanning the chest and abdomen/pelvis (group 2, n=44). The mean scan time was 21 min in group 1 and 25 min in group 2 (P=0.01). The mean repositioning time in group 2 was 8 min. Significantly, more artifacts were observed in group 1 (with a repeated scan in 7%) than in group 2 (P=0.0001). This novel multiple- trauma CT-scanning protocol with patient repositioning achieves a higher image quality with significantly fewer artifacts than without repositioning but increases scan time slightly.

Staged management and outcome of combined pelvic and liver trauma. An international experience of the deadly duo

Pelvic fracture associated with liver trauma is not an uncommon injury combination in multiple trauma and is associated with high morbidity and mortality. The aim of this study was to examine the characteristics of this specific patient group, to describe the diagnostic and treatment protocols and finally to analyse risk factors associated with mortality. Data were collected over a 6-year period, ending in 2001. The pelvic injury was graded according to the Tile classification system and the hepatic injury was scored using the organ injury scale (OIS). Treatment protocol, associated injuries, complications, length of ICU/Hospital stay and mortality were recorded and analysed. A total of 140 patients (40% female) with a mean age of 35.1+/-15.9 years and a median ISS of 41 were included in this study. The overall mortality rate was 40.7%. Binomial logistic regression analysis revealed age, initial blood pressure, transfusion requirement as well as the severity of head, chest, spleen and liver injury as independent parameters predicting reduced survival rates. This deadly duo of injuries presents a challenge to the trauma surgeon. Rapid assessment and treatment is required to prevent death by haemorrhage. The presence of concomitant injuries renders the patient very sensitive to ongoing or additional physiological disturbance. The principles of 'damage control surgery' must be applied to avoid complications such as acute respiratory distress syndrome (ARDS) and multiple organ dysfunction syndrome (MODS).

CT in blunt liver trauma

Nonsurgical treatment has become the standard of care in hemodynamically stable patients with blunt liver trauma. The use of helical computed tomography (CT) in the diagnosis and management of blunt liver trauma is mainly responsible for the notable shift during the past decade from routine surgical to nonsurgical management of blunt liver injuries. CT is the diagnostic modality of choice for the evaluation of blunt liver trauma in hemodynamically stable patients and can accurately help identify hepatic parenchymal injuries, help quantify the degree of hemoperitoneum, and reveal associated injuries in other abdominal organs, retroperitoneal structures, and the gastrointestinal tract. The CT features of blunt liver trauma include lacerations, subcapsular or parenchymal hematomas, active hemorrhage, juxtahepatic venous injuries, periportal low attenuation, and a flat inferior vena cava. It is important that radiologists be familiar with the liver injury grading system based on these CT features that was established by the American Association for the Surgery of Trauma. CT is also useful in the assessment of delayed complications in blunt liver trauma, including delayed hemorrhage, hepatic or perihepatic abscess, posttraumatic pseudoaneurysm and hemobilia, and biliary complications such as biloma and bile peritonitis. Follow-up CT is needed in patients with high-grade liver injuries to identify potential complications that require early intervention.

Classification of liver and pancreatic trauma

The liver is the most frequently injured intra-abdominal organ and associated injury to other organs increases the risk of complications and death. This has highlighted the critical need for an accurate classification system as a basis for the clinical decision-making process. Several classification systems have been proposed in an attempt to incorporate the aetiology, anatomy and extent of injury and correlate it with subsequent clinical management and outcome. The widely accepted Organ Injury Scale is based on anatomical criteria that quantify the disruption of the liver parenchyma and defines six groups which may influence management strategies and relate to outcome. The less common pancreatic injury remains a major source of morbidity and mortality due to the likelihood of associated solid or hollow-organ injuries. The implication of a delay in diagnosis and management emphasizes the need for an accurate classification system. The Organ Injury Scale is widely used for pancreas trauma and recognizes the importance of progressive parenchymal injury and in particular ductal injury. Advances in imaging techniques have led to the development of newer radiological classification systems; however, validation of their accuracy remains to be proven. An accurate classification of liver and pancreatic trauma is fundamental for the development of treatment protocols in which clinical decisions are based on the severity of injury.

Transcatheter arterial embolization in a hemodynamically unstable patient with grade IV blunt liver injury: is nonsurgical management an option?

The prevalence of liver injury in patients who have sustained blunt multiple trauma was reported to range from 1 to 8%. Because previous mortality rates were as high as 50-80% for severe hepatic injury, the choice of treatment was under intensive investigation. Whereas nonsurgical management was the standard treatment for the hemodynamically stable patient, there is no consensus on how to treat hemodynamically unstable patients. This report details the case of a patient who sustained blunt multiple trauma, resulting in a grade IV liver injury, graded according to the American Association for the Surgery of Trauma (AAST) Liver Injury Scale. With massive fluid and blood resuscitation, the patient was stable enough to be managed nonsurgically. With transcatheter arterial embolization (TAE), the left and right hepatic arteries were embolized with coils, which allowed for a good recovery. We hypothesize that TAE can be used in the hemodynamically unstable patient who responds to rapid fluid resuscitation and blood transfusion. We caution that there is insufficient evidence until now and would therefore not make any recommendations; however, we would question the need for surgery in unstable patients with this kind of injury in the future.

Eleven years of liver trauma: the Scottish experience

The aim of this population based study was to assess the incidence, mechanisms, management, and outcome of patients who sustained hepatic trauma in Scotland (population 5 million) over the period 1992-2002. The Scottish Trauma Audit Group database was searched for details of any patient with liver trauma. Data on identified patients were analyzed for demographic information, mechanisms of injury, associated injuries, hemodynamic stability on presentation, management, and outcome. A total of 783 patients were identified as having sustained liver trauma. The male-to-female ratio was 3:1 with a median age of 31 years. Blunt trauma (especially road traffic accidents) accounted for 69% of injuries. Liver trauma was associated with injuries to the chest, head, and abdominal injuries other than liver injury; most commonly spleen and kidneys. In all, 166 patients died in the emergency department, and a further 164 died in hospital. The mortality rate was higher in patients with increasing age (p < 0.001), hemodynamic instability (p < 0.001), blunt trauma (p < 0.001), and increasing severity of liver injury (p < 0.001). The incidence of liver trauma in Scotland is low, but it accounts for significant mortality. Associated injuries were common. Outcome was worse in patients with advanced age, blunt trauma, multiple injuries and those requiring an immediate laparotomy.

Predictive factors of liver injury in blunt multiple trauma

INTRODUCTION

This study was conducted to clarify whether injuries that are likely to be revealed by initial clinical and conventional radiological examination at the trauma bay (e.g., right-side rib fractures) meaningfully contribute to the prior probability of accompanying hepatic lesions in multiple injured patients.

MATERIAL AND METHODS

Fifty-five subjects (sampled from a cohort of 218 patients) with liver injury fulfilling the definition of polytrauma were compared with 55 polytrauma patients without liver injury. Controls were individually matched for age, gender, and Injury Severity Scores. Whole-body, helical, contrast-enhanced computed tomography was applied to all participants. We modeled independent predictors of liver involvement by conditional logistic and random-effects regression analysis.

RESULTS

In the present sample, the prevalence of hepatic injury was 25.2%. Neither the injury mechanism (car crash, pedestrian accident, fall from height) nor certain accompanying injuries (right-side serial rib fractures, lumbar spine fractures) predicted the presence of hepatic injury. Liver injury was particularly unlikely in bikers [odds ratio (OR) 0.78, 95% confidence interval (CI) 0.59-1.03] and patients with left-side rib fractures (OR 0.80, 95% CI 0.66-0.98).

DISCUSSION

There are no index injuries that will reliably indicate the presence of liver involvement in multiple trauma cases. Also, the absence of these injuries cannot rule out liver damage.

Multi-detector row CT imaging of blunt abdominal trauma

CT is the imaging modality of choice to evaluate hemodynamically stable patients suffering blunt abdominal trauma. During the past five years, single-slice helical CT has been replaced by multidetector row CT (MDCT). This development has revolutionized cross-sectional imaging for blunt trauma patients. Volumetric imaging with helical CT has been a major factor supporting the nonoperative management of solid organ injury. Trauma centers in the United States are replacing single-slice helical CT scanners with state-of-the-art MDCT in suites proximate to the patient receiving area and with facilities for monitoring and maintaining physiologic support. The ability to obtain high-resolution images with MDCT during optimal contrast enhancement at unparalleled speed helps detect the presence and define the extent of injuries, and crucially, to diagnose hemorrhage and vascular injuries. This article describes our current imaging protocol with MDCT-16 (i.e., 16 detector MDCT), the spectrum of diagnostic findings seen in blunt abdominal injury, and the role of MDCT in the characterization of hemorrhage and planning injury management.