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Liver Injury

A liver injury can be sustained through blunt (motor vehicle accident) or penetrating (knife or gunshot) trauma. Due to the location and high vascularity of the liver, it is vulnerable to injury and serious consequences such as hemorrhage.


Presentation

The large and highly vascular liver is located in the right upper quadrant, which is underneath the diaphragm. Hence the position of the liver renders it susceptible to shear forces [1]. Moreover, it is the most frequently harmed organ in blunt abdominal trauma and second most commonly affected organ in penetrating mechanisms [2].

The clinical presentation of patients with liver injury consists of abdominal and right chest wall pain and referred pain to the right shoulder. Also, the patient will very likely exhibit peritoneal signs. Mental status changes may occur as well.

Complications

Among the serious outcomes that develop in a considerable number of people with liver trauma is delayed hemorrhage, hepatic or perihepatic abscess, bile duct injury leading to the formation of biloma, and abdominal compartment syndrome [3] [4].

Physical exam

The vital signs may point to hemodynamic instability and hemorrhagic shock. Other remarkable findings include abdominal and chest wall tenderness along with abdominal distension. Additionally, hematomas may be notable.

The clinician must perform a thorough physical exam investigating all possible injuries since the vast majority of patients will have additional trauma. Specifically, the chest and spleen are the most commonly involved accompanying a liver injury [5]. Blunt trauma can also cause rib and pelvic fractures and spinal cord injuries.

Pathologist
  • The pathologist plays a key role in the evaluation of DILI by classifying and interpreting the histologic findings considering patients' medical history and drug exposure.[ncbi.nlm.nih.gov]
Chest Wall Tenderness
  • Other remarkable findings include abdominal and chest wall tenderness along with abdominal distension. Additionally, hematomas may be notable.[symptoma.com]
Abdominal Pain
  • Liver function tests should be performed when there is upper abdominal pain after administration of clomiphene citrate.[ncbi.nlm.nih.gov]
Dyspepsia
  • We report a patient who developed severe liver injury requiring listing for liver transplantation for improved survival, after consumption of Bhasma for dyspepsia.[ncbi.nlm.nih.gov]
Scleral Icterus
  • On physical examination, scleral icterus was noted. Workup revealed elevated liver transaminases, alkaline phosphatase, and conjugated bilirubin.[ncbi.nlm.nih.gov]
  • Patients should be advised to promptly report any new-onset symptoms such as scleral icterus, abdominal pain/discomfort, nausea/vomiting, pruritis, or choluria.[gi.org]

Workup

In order to understand the extent of the damage, the trauma team should inquire about how the patient acquired the injury. Other crucial components of the workup include a thorough physical exam and imaging studies. Moreover, newer innovations in imaging techniques have not only improved the diagnostic accuracy, these also paved the way for conservative management.

Imaging

In hemodynamically stable patients with blunt abdominal trauma, computed tomography (CT) is the imaging modality of choice [6] [7]. The CT scan will provide information about the abdominal and retroperitoneal structures, the severity of hemoperitoneum, and other complications [8]. This imaging test demonstrates up to 97% sensitivity and nearly 99% specificity for liver injuries [9]. Furthermore, CT scanning is significant in the nonsurgical management of patients with liver injury as experts advocate for follow-up studies to assess the presence of delayed complications and resolution [4].

The focused assessment with sonography for trauma (FAST) test is used as a rapid bedside evaluation to identify the presence of hemoperitoneum [10]. Both the sensitivity and specificity of FAST may reach up to 100% [10]. Contrast-enhanced ultrasonography can improve evaluation of blunt trauma [11] as non-contrast sonography may fail to detect the presence of blood or injuries to intraabdominal and retroperitoneal organs.

Angiography assists in the detection of active bleeding sites, which can be treated with angioembolization.

Magnetic resonance cholangiopancreatography (MRCP) is useful for evaluation of bile duct injuries [12].

Diagnostic peritoneal lavage was previously utilized for diagnosis of blunt trauma [13], but CT and FAST are preferred.

Dyslipidemia
  • The second case presents with asymptomatic hepatocellular toxicity and marked dyslipidemia identified on service-related physical following 21 days of prohormone use.[ncbi.nlm.nih.gov]

Treatment

  • Liver injury fully improved after initiation of corticosteroid for the treatment of adrenal insufficiency.[ncbi.nlm.nih.gov]

Prognosis

  • CONCLUSIONS: Our work summarises current knowledge regarding clinical presentation, disease course, and prognosis of TCM-ILI. TCM can result in hepatotoxicity, even death or necessitate life-saving liver transplantation.[ncbi.nlm.nih.gov]
  • In addition, improved prognosis of patient outcome or accelerated identification of the underlying etiology may be facilitated by more detailed knowledge of effectors and targets related to acute liver failure.[journal.frontiersin.org]
  • Conclusion Acquired liver injury and hepatotoxicity occur frequently in critically ill patients and affect prognosis. The main causes of acquired liver injury include shock, sepsis, drugs, and parenteral nutrition.[anesthesiology.pubs.asahq.org]
  • The impact of eosinophilia and hepatic necrosis on prognosis in patients with drug-induced liver injury. Aliment Pharmacol Ther 2007;25:1411–1421. 36. Rochon J, Protiva P, Seeff LB et al.[gi.org]

Etiology

  • This implies an immune-mediated etiology of DILI, especially ciprofloxacin-induced cholestatic liver injury. DILI is challenging to diagnose in the setting of multiple comorbidities.[ncbi.nlm.nih.gov]
  • New approaches for the treatment of certain etiologies and of acute liver failure in general could be derived from molecular targets or mechanisms involved in these processes.[journal.frontiersin.org]

Epidemiology

  • Organizations of Medical Sciences (CIOMS), the Roussel Uclaf Causality Assessment Method (RUCAM) is the most used causality assessment tool worldwide for the diagnosis of drug-induced liver injury (DILI) and herb-induced liver injury (HILI) in a large number of epidemiological[ncbi.nlm.nih.gov]
  • , Ruth Brauer , research student , Liam Smeeth , professor of clinical epidemiology 1 Faculty of Epidemiology and Population Health, London School of Hygiene and Tropical Medicine, London WC1E 7HT, UK Correspondence to: I Douglas ian.douglas{at}lshtm.ac.uk[bmj.com]
  • Shock 2009; 32:358–65 Larrey D: Epidemiology and individual susceptibility to adverse drug reactions affecting the liver.[anesthesiology.pubs.asahq.org]
  • HDS induced liver injury Epidemiology HDS hepatotoxicity has received increasing attention over the past few years, in part owing to the recognition in the United States that among DILI cases HDS are the second most common cause ( 16 ).[gi.org]
Sex distribution
Age distribution

Pathophysiology

  • In this review, we will discuss the pathophysiological mechanisms underlying DILI.[ncbi.nlm.nih.gov]
  • Rowan van Golen studies a number of pathophysiological aspects of this type of injury, and the interaction between parenchymal liver pathology and surgery-induced liver injury. R.F. van Golen: A Treatment Rationale for Surgery-Induced Liver Injury.[uva.nl]
  • Mushlin and Simon Gelman , Hepatic Physiology and Pathophysiology , Miller's Anesthesia , 10.1016/B978-0-443-06959-8.00017-0 , (411-440) , (2010) . Krishnamoorthy Ramkumar, M Thamara P.R. Perera, Ravi Marudanayagam, Chris Coldham, Simon P.[dx.doi.org]

Prevention

  • OA scavenged ROS, prevented oxidative damage and maintained the normal structure of mitochondria. We further confirmed that OA increased adenosine triphosphate (ATP) by promoting the TCA production cycle and oxidative phosphorylation (OXPHOS).[ncbi.nlm.nih.gov]

Summary

References

Article

  1. Piper GL, Peitzman AB. Current management of hepatic trauma. Surg Clin North Am. 2010; 90(4):775–85.
  2. Tinkoff G, Esposito TJ, Reed J, et al. American Association for the Surgery of Trauma Organ Injury Scale I: spleen, liver, and kidney, validation based on the National Trauma Data Bank. J Am Coll Surg. 2008; 207:646.
  3. Goldman R, Zilkoski M, Mullins R, et al. Delayed celiotomy for the treatment of bile leak, compartment syndrome, and other hazards of nonoperative management of blunt liver injury. Am J Surg. 2003; 185(5):492-497.
  4. Yoon W, Jeong YY, Kim JK, et al. CT in blunt liver trauma. Radiographics. 2005; 25(1):87-104.
  5. Sánchez-Bueno F, Fernández-Carrión J, Torres Salmerón G, et al. Changes in the diagnosis and therapeutic management of hepatic trauma. A retrospective study comparing 2 series of cases in different (1997-1984 vs. 2001-2008). Cir Esp. 2011; 89(7):439.
  6. Poletti PA, Mirvis SE, Shanmuganathan K, et al. CT criteria for management of blunt liver trauma: Correlation with angiographic and surgical findings. Radiology. 2000; 216(2):418–27.
  7. Delgado Millan MA, Deballon PO. Computed tomography, angiography, and endoscopic retrograde cholangiopancreatography in the nonoperative management of hepatic and splenic trauma. World J Surg. 2001; 25(11):1397-1402.
  8. Pachter HL, Knudson MM, Esrig B, et al. Status of nonoperative management of blunt hepatic injuries in 1995: a multicenter experience with 404 patients. J Trauma. 1996; 40(1):31-38.
  9. Hoff WS, Holevar M, Nagy KK, et al. Practice management guidelines for the evaluation of blunt abdominal trauma: Eastern Asociation for the Surgery of Trauma. J Trauma. 2002; 53(3):602-15.
  10. Scalea TM, Rodriguez A, Chiu WC, et al. Focused assessment with sonography for trauma (FAST): results from an international consensus conference. J Trauma. 1999; 46(3):466–72.
  11. Catalano O, Lobianco R, Raso MM, Siani A. Blunt hepatic trauma: Evaluation with contrast-enhanced sonography. J Ultrasound Med. 2005;24(3):299–310.
  12. Fulcher AS, Turner MA, Yelon JA, et al. Magnetic resonance cholangiopancreatography (MRCP) in the assessment of pancreatic duct trauma and its sequelae: preliminary findings. J Trauma. 2000; 48(6):1001-7.
  13. Trunkey DD. Hepatic trauma: Contemporary management. Surg Clin North Am. 2004; 84(2):437–50.

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Last updated: 2019-07-11 22:19