Leberverletzungen

Isoliert
intraparenchymatöse Leberruptur nach direkter, stumpfer Gewalteinwirkung. Rippenfraktur, aber kein Pneumothorax, fast keine freie Flüssigkeit.
Wikipedia • CC BY-SA 4.0
Preschooler
who fell out of a second story window and has right upper quadrant pain. Axial CT with contrast of the abdomen shows two low density poorly circumscribed lesions in the right lobe of the liver.The diagnosis was liver laceration.
pediatricimaging.org • CC-by-nc-sa 4.0
School ager
after motor vehicle accident. Axial CT with contrast of the abdomen shows a low density triangular shaped lesion in the middle of the liver.The diagnosis was liver laceration.
pediatricimaging.org • CC-by-nc-sa 4.0
School ager
post motor vehicle accident. Axial CT with contrast of the abdomen shows a low density bear claw shaped lesion in the right lobe of the liver that is lateral to and inferior to the gall bladder.The diagnosis was liver laceration.
pediatricimaging.org • CC-by-nc-sa 4.0
Teenager with
abdominal pain after a motor vehicle accident. Axial CT with contrast of the abdomen shows a low density lesion in the posterior aspect of the right lobe of the liver. The diagnosis was liver laceration.
pediatricimaging.org • CC-by-nc-sa 4.0
Zentrale,
gedeckte Leberruptur in der Comutertomographie: Irreguläre, hypodense Läsionen im Leberparenchym ohne Erreichen der Oberfläche und somit ohne subkapsuläres Hämatom oder freie Flüssigkeit im Abdomen.
Wikipedia • CC BY-SA 4.0
A case of
acute abdomen caused by ruptured bifocal HCC. CT image performed after injection of contrast medium reveals active intraperitoneal bleeding (arrow) in subhepatic space.
www.eurorad.org • CC by-nc-sa-4.0
A case of
acute abdomen caused by ruptured bifocal HCC. CT image performed after injection of contrast medium reveals another protrusive capsulated hepatic nodule in VI segment, presenting peripheral hypodense area (arrow), suggesting the point of rupture through the liver capsule.
www.eurorad.org • CC by-nc-sa-4.0
Preschooler
who fell 20 feet out a window with abdominal painAxial CT with contrast of the abdomen shows a large amount of fluid in the region of the right adrenal gland and areas of low density in the middle and posterior aspects of the right lobe of the liver.The diagnosis was right adrenal hemorrhage and liver laceration.
pediatricimaging.org • CC-by-nc-sa 4.0
Peliosis
hepatis. Coronal contrast-enhanced CT demostrating a complex mass in the left liver lobe with hypo and isodense areas and presence of vessels with contrast. Perihepatic free fluid of high attenuation in relation with haemoperitoneum.
www.eurorad.org • CC by-nc-sa-4.0
Grade 4 liver
laceration
Wikipedia • CC BY-SA 4.0
Post-traumatic
serpentine type hepatic artery pseudoaneurysms. Axial CECT arterial phase shows large poorly defined heterogenous hypodensity in right lobe of liver indicating Grade VI injury (AAST Grading). Note multiple large serpentine pseudoaneurysms in right lobe (arrow) and gross haemoperitoneum.
www.eurorad.org • CC by-nc-sa-4.0
Fatal liver
mass rupture in a common-variable-immunodeficiency patient with probable nodular regenerating hyperplasia. Hepatic imaging A–D. The initial multiphasic CT. A The non-contrasted image shows no abnormal intrahepatic bleeding. B The arterial phase shows multiple poorly-defined, arterial-enhancing nodules scattered throughout both hepatic lobes (white arrows). In portovenous phase C and 5 min-delayed phase D, these nodules remain iso- to hyperattenuating compared to the adjacent liver parenchyma. Hepatic imaging E–F. The 7-month follow-up CT. E The non-contrasted image shows multiple areas of intrahepatic bleeding (black arrowheads) and intraperitoneal bleeding (black arrows). F The portovenous phase demonstrates disruption of the liver capsule (white arrowhead), suggesting rupture of these hypervascular liver lesions
aacijournal.biomedcentral.com • CC-by-4.0
Post-traumatic
serpentine type hepatic artery pseudoaneurysms. Coronal CECT arterial phase shows the right lobe liver laceration and pseudoaneurysm.
www.eurorad.org • CC by-nc-sa-4.0
Post-traumatic
serpentine type hepatic artery pseudoaneurysms. Axial CECT portal phase image shows clearly hepatic laceration, intraparenchymal haematoma and serpentine pseudoaneurysms.
www.eurorad.org • CC by-nc-sa-4.0
School ager
in a motor vehicle accident with abdominal pain. Axial CT with contrast of the abdomen shows an area of low density in the right lobe of the liver and a large amount of free fluid in the pelvis.The diagnosis was liver laceration with hemoperitoneum.
pediatricimaging.org • CC-by-nc-sa 4.0
School ager
with abdominal pain after motor vehicle accident. AXR AP (above) obtained after an outside upper GI exam which demonstrated normal bowel rotation shows contrast filling multiple dilated loops of small bowel. Initial AP image from an enema (below left) shows a microcolon with contrast almost reaching the cecum. Later image from the enema (below right) shows reflux of contrast into dilated loops of distal ileum in the right lower quadrant.The diagnosis was liver laceration with associated right adrenal hemorrhage.
pediatricimaging.org • CC-by-nc-sa 4.0
Radiopaedia • CC-by-nc-sa 3.0 • de

The liver is one of the most frequently damaged organs in blunt trauma, and liver trauma is associated with a significant mortality rate.

Epidemiology

In blunt abdominal trauma, the liver is injured ~5% (range 1-10%) of the time .

Clinical presentation

Patients can present with right upper quadrant pain, right shoulder tip pain (from diaphragmatic irritation), hypotension, and shock .

Pathology

Etiology

The mechanism for liver trauma can be from blunt (e.g. motor vehicle collision, fall, direct blow, etc.) or penetrating trauma (e.g. gunshot, stabbing). It can also be iatrogenic (e.g. percutaneous liver biopsy).

Types

Most (~80%) of liver injuries are minor (grades I to III). There is a range of injuries:

  • laceration (most common)
  • hematoma - subcapsular or intraparenchymal
  • active hemorrhage
  • major hepatic vein injury
  • arteriovenous (AV) fistula
  • bile duct injury
Associations

Approximately 80% of liver injuries are associated with other abdominal injuries .

Within the liver:

  • lacerations that involve a hepatic vein are associated with increased risk of arterial injury and need for operative management
  • although not an injury, periportal edema can be seen associated with liver injuries as patients with higher-grade injuries will have received aggressive fluid resuscitation
  • lacerations that extend to the porta hepatis increase the risk of bile duct injuries, particularly delayed biliary complications
  • bile duct injuries are more common in :
    • higher grade injuries
    • central injuries, that is injuries that are close to the IVC
    • penetrating trauma, compared with blunt trauma

Outside the liver (known as secondary signs):

Markers

Elevated liver transaminases (ALT/AST) are 100% specific and ~93% sensitive in predicting liver injuries .

Radiographic features

CT

CT is the investigation of choice for evaluating liver trauma. It is ~95% sensitive and 99% specific for detecting liver injuries .

  • lacerations appear as irregular linear/branching areas of hypoattenuation
  • hematomas appear as a hypodensity between the liver and its capsule (and can be differentiated from intra-peritoneal hematoma as these distort the liver architecture) or can be intraparenchymal
  • acute hematomas/hemorrhage are typically hyperdense (40-60HU) compared to normal liver parenchyma
  • muscular diaphragmatic slips may simulate a peripheral laceration but are smoother, non-branching and of muscle density when compared to a laceration

If the liver is diffusely hypoattenuating, such as seen in steatosis, lacerations and hematomata may be more subtle to diagnose . Secondary signs should help.

See the main article liver injury grading for more details.

Hepatic scintigraphy

Scintigraphy, such as that using Tc-99m mebrofenin or disofenin, is the most commonly used test for the diagnosis of bile leaks . A contained leak will demonstrate an extrabiliary focus of radiotracer which remains stable in size and morphology during all the phases of the study. A free intraperitoneal bile leak will demonstrate an extraluminal collection of radiotracer in the peritoneal cavity that varies or increases in time .

Differential diagnosis

Several mimics of liver lacerations and hematomata exist, and include :

  • focal fat infiltration
  • unenhanced aberrant portal or hepatic veins
  • congenital fissures and clefts: typically fat density, and in usually locations
  • diaphragmatic slips or eventration: identifiable on coronal images
  • pre-existing liver lesions

Treatment and prognosis

Most (>80%) of liver injuries can be treated non-surgically, and in blunt trauma relies on hemodynamic stability rather than a grade of injury . There is a significant mortality rate of ~8% (range 4.1-11.7%) associated with liver trauma . Complications are reported in ~20% of cases of non-operatively treated liver trauma :

Siehe auch:
und weiter:
Assoziationen und Differentialdiagnosen zu Leberverletzungen:
subkapsuläres
Leberhämatom
Wikipedia • CC BY-SA 3.0
Leberhämatom
 
Wikipedia • CC BY-SA 4.0
stumpfes
Bauchtrauma
Wikipedia • CC BY-SA 3.0