liver trauma
Introduction
Introduction to liver trauma Liver trauma is a common and serious injury in abdominal trauma. Its incidence is second only to spleen rupture, and the severe liver injury is complicated, with many complications and high mortality. Therefore, it is necessary to explore such damage. Diagnosis and treatment are still important topics in current abdominal trauma. Liver trauma is often caused by firearm injuries or sharp injuries during wartime, mainly open injuries. In normal times, most of them are blunt injuries, such as crush injuries, traffic accident injuries, blunt blows, falls, etc., mainly closed injuries, and traffic accidents are the most common. basic knowledge The proportion of illness: 0.03% Susceptible people: no specific population Mode of infection: non-infectious Complications: anemia, sepsis, shock, biliary peritonitis, biliary bleeding, acute renal failure, stress ulcer
Cause
Cause of liver injury
(1) Causes of the disease
According to the cause of injury, liver injury is generally divided into open injury and closed injury. Open injury generally has knife stab wound, firearm wound, etc., knife stab wound is relatively light, and the mortality rate is low. The firearm injury is powered by gunpowder. The open injury caused by projectiles (projectiles, shrapnel, marbles) is more common in war wounds. Liver firearm injuries are the most common type of abdominal firearm injuries. Open injuries can be divided into blind tube injuries and penetrating injuries. Kind of abdominal closed injury is more common with blunt injury, mainly due to impact, extrusion, common in road traffic accidents, building collapse, occasionally falling at high places, sports injuries or bruises.
Because of the closed injury of the abdomen, in addition to liver injury, often combined with other organ damage, and no signs of injury on the abdomen surface, the diagnosis is relatively difficult to lead to treatment delay, so blunt trauma is more dangerous, and the mortality rate is often higher than the open injury.
(two) pathogenesis
The pathophysiological changes in early liver injury are mainly hemorrhagic, hemorrhagic shock and biliary peritonitis. The latter not only aggravates the loss of extracellular fluid, but also affects the normal coagulation mechanism, causing secondary bleeding and infection.
The pathological changes of liver injury vary with the nature of the injury. The liver parenchymal damage caused by stab wounds and cuts is generally light. Gunshots and shrapnel often cause penetrating wounds or blind tube injuries. The degree of damage and the damage location and warhead speed are Close relationships are usually represented by the following formula:
In the formula, m-projection damage, v-projection speed, when the projection speed is slightly increased by the above formula, the generated kinetic energy is squared. In addition, the damage caused by the irregularity of the shrapnel is heavier, and the damage caused by the high-speed warhead along the trajectory. The liver tissue can be separated and detached.
The location of liver laceration is often at the attachment of the ligament around the liver, or consistent with the direction of the ribs and spine. The closed liver trauma mainly causes the following three kinds of injuries.
1. Hepatic subcapsular hematoma: the surface of the liver parenchyma is ruptured, and the liver capsule is still intact, then the blood accumulates under the capsule, the hematoma size varies, sometimes it can accommodate 2 to 4 L of blood, and if it is infected, an abscess is formed. Once the capsule is ruptured, it turns into a true liver rupture, sometimes the hematoma oppresses the liver parenchyma, causing massive liver tissue necrosis.
2. Central rupture of the liver: the central part of the liver parenchyma is ruptured, the surface tissue is still intact, often accompanied by the rupture of hepatic vessels and bile ducts, forming a large intrahepatic hematoma and bile retention, and extensive tissue necrosis caused by compression of the tissue. Infection or communication with large intrahepatic bile ducts, and biliary bleeding.
3. Liver rupture: liver parenchyma and liver capsule are ruptured, blood and bile directly flow into the abdominal cavity, but the degree of damage and pathological changes are very different, can be divided into:
1 liver parenchymal laceration, single or multiple lacerations, regular or irregular or starburst laceration, simple hepatic parenchymal injury or combined with intrahepatic, posterior hepatic vascular injury;
2 liver parenchyma is broken, the liver tissue of the distal end of the liver is deprived of blood and loses vitality;
3 liver parenchymal damage, liver tissue ruptured or shedding to the abdominal cavity due to severe injury, losing the normal shape of the liver, necrotic liver tissue liquefaction, infection, the formation of abscess in the abdomen.
Intrahepatic and extrahepatic bile duct injury can cause bile overflow, produce biliary peritonitis, and hepatic portal area vascular injury, causing hepatic ischemia and acute intra-abdominal hemorrhage.
Prevention
Liver trauma prevention
There is no effective preventive measure for this disease. Early detection and early diagnosis are the key to the prevention and treatment of this disease.
Usually pay attention to nutrition
If the body is malnourished, suffering from anemia, vitamin deficiency, etc., this will directly affect the resistance of the wound and the healing ability of the wound. The resistance is too low, which in turn can lead to the wound not being healed for a long time. The blood, foreign body and surrounding necrotic tissue at the wound can not only cause inflammation of the wound, but also provide a favorable breeding for bacteria in the wound. The condition is followed by continued infection and suppuration.
Complication
Liver trauma complications Complications anemia septic shock biliary peritonitis biliary tract bleeding acute renal failure stress ulcer
1. Infection: The most common and the main cause of late death. All wounds of firearm wounds are infected. Because the projectile penetrates the tissue, it can bring the dirt into the wound. In addition, the liver wounds are bleeding and leaking. Liver necrosis, combined with hollow organ injury can lead to infection, the type of infection is generally divided into underarm abscess, intrahepatic abscess, pelvic abscess, incision purulent, thoracic abscess or other parts of the body abscess, liver blood supply is rich, once infected patients Rapid symptoms of severe poisoning, such as high fever, anemia, hypoproteinemia, etc., severe infections will lead to sepsis, shock, so when handling liver trauma, the drainage tube must be placed and kept open to prevent the accumulation of fluid under the liver. When intrahepatic, axillary, and pelvic abscesses occur, BUS, CT, etc. should be used for examination and positioning, and puncture drainage should be performed. If necessary, the drainage should be cut in time.
2. Biliary leakage: common complications, caused by: liver injury, large bile duct branching incomplete liver suture, necrotic liver tissue incomplete removal, liquefaction and ulceration caused by hepatic tube branch rupture, suture wound The bile duct of the draining liver segment is ligated, resulting in increased peripheral pressure of the bile duct, plus infection and rupture, so that bile overflows. If effective drainage is not established, biliary peritonitis often occurs, and severe shock death, small bile leakage The drainage of time can be cured, but the large bile leakage lasts for a long time. A few need to be operated again. Those who have formed sinus can be placed into a drainage tube through the sinus. After 3 to 6 months, the angiographic examination is performed to determine the treatment plan. .
3. Rebleeding: It is the main cause of early death of liver trauma. Early hemorrhage is mostly related to incomplete hemostasis during operation. Late hemorrhage occurs mostly in the days after injury, dozens of days, secondary bleeding, and more inactivation. It is related to necrosis of liver tissue. In addition, a large amount of blood is injected into the liver during liver injury. The liver function declines after liver injury and the blood coagulation mechanism is an important cause of postoperative bleeding. Therefore, the blood is completely stopped as needed during surgery, and the blood is fully drained. Whenever possible, use blood, if necessary, apply platelets, blood coagulation factors, etc. Once secondary bleeding occurs, it is often necessary to perform hepatic artery ligation or tamponade to stop bleeding.
4. Traumatic biliary hemorrhage: can occur in the early postoperative period, but also in a few weeks, several months later, the bleeding is mostly caused by central liver rupture, intrahepatic hematoma after rupture to the intrahepatic bile duct and cause biliary bleeding, It is characterized by hematemesis, melena, and upper abdominal cramps. The main treatment methods are surgery. Hematoma incision and hemostasis, hepatic artery ligation or hepatectomy, and common bile duct T-tube drainage.
5. Multiple system organ dysfunction syndrome (MODS): caused by severe injury, massive hemorrhage, severe shock and infection, mainly manifested as acute renal failure (ARF), respiratory distress syndrome (ARDS), stress ulcer Therefore, in the treatment of liver injury, timely anti-shock, correct the imbalance of homeostasis, prevention and treatment of infection is very important to prevent MODS.
Symptom
Symptoms of liver trauma Common symptoms Abdominal tenderness dull pain Abdominal muscle tension Repeated bleeding Blood pressure drop Nausea shock Unconsciousness Responsive dull peritoneal irritation
The patient generally has a clear history of right chest and abdomen trauma. The awake patient complains of pain in the right upper quadrant, sometimes radiates to the right shoulder. He feels thirsty, nausea, vomiting, and signs of liver trauma are mainly hypovolemic shock and peritonitis. The patient has intra-abdominal hemorrhage, and abdominal distension can also occur. The clinical manifestations of hepatic trauma are also inconsistent due to the different causes of injury.
Hepatic subcapsular hematoma or small hematoma in the liver parenchyma, clinically mainly liver disease dull pain, the body can be seen in the liver or upper abdominal mass, if the hematoma and biliary tract communication, it is manifested as biliary bleeding, causing upper gastrointestinal bleeding Long-term repeated hemorrhage can lead to chronic progressive anemia. If the hemorrhage in the hematoma continues to increase, the hepatic capsule tension is too large, and suddenly rupture under external force, acute hemorrhagic shock occurs. Therefore, when non-surgical treatment is performed for patients with subcapsular hematoma, Must pay attention to the possibility of delaying bleeding, if the hematoma secondary infection, there may be signs of liver abscess, high fever, liver pain and other liver abscess.
In the case of superficial laceration of the liver, due to the small amount of bleeding, bile extravasation is not much, and in a short period of time, bleeding can stop itself. Generally, only the right upper quadrant is painful, and shock and peritonitis rarely occur.
Central liver rupture or open liver injury Liver tissue fragmentation is extensive, generally involving large blood vessels and bile ducts, intra-abdominal hemorrhage, bile extravasation, patients often have acute shock symptoms and peritoneal irritation, manifested as abdominal pain, The face is pale, the pulse is fine, the blood pressure is lowered, the urine volume is reduced, the abdominal tenderness is obvious, and the abdominal muscles are tense. As the bleeding increases, the above symptoms are further aggravated.
Severe hepatic rupture of the liver or rupture of large blood vessels near the hilar, such as the portal vein, inferior vena cava, etc., can occur uncontrollable major bleeding, large blood vessel damage can lead to a large number of dynamic blood loss and cause fatal hypovolemic shock, often Died in the treatment process, lost the opportunity for surgical treatment.
Open liver injury is easier to make a diagnosis, but it is necessary to pay attention to whether there is a combined chest and abdomen injury. Closed injury with typical hemorrhagic shock and peritoneal irritation combined with a history of trauma is easy to diagnose, but for some patients with combined injuries Patients, such as brain trauma, unclear, multiple fractures with shock, elderly and frail slow response should be vigilant, so as not to miss the diagnosis, liver cirrhosis or liver cancer patients with mild trauma can cause liver rupture, can not be taken lightly, abdominal closed injury Whether the liver injury is combined or not involves the operation of open surgery, so the accuracy of the diagnosis is high. When the diagnosis is doubtful, abdominal cavity puncture, abdominal lavage and other auxiliary examinations can assist the diagnosis.
Examine
Liver injury examination
There was no obvious change in the early stage of mild liver trauma. Due to rapid blood loss and blood concentration, many patients did not show hemoglobin changes, but the white blood cells of patients with liver trauma often were >1.5×109/L.
The diagnostic accuracy of abdominal puncture for closed hepatic trauma is about 70% to 90%, and can be repeated. The results of 113 cases of closed hepatic trauma with abdominal puncture in Shanghai Eastern Hepatobiliary Surgery Hospital, 105 cases were positive, and the diagnostic positive rate was 92.9%. Before puncturing, it is required to empty the bladder. Under local anesthesia, a large needle of 18 to 19 is used for puncture in the four quadrants of the abdomen of the rectus abdominis. The scar tissue of the abdominal wall should be avoided. If the blood is not coagulated, it is positive. The result of the puncture is a false negative. It may be due to the intra-abdominal hemorrhage of less than 200 to 500 ml. It may also be accompanied by a rupture of the diaphragm, which causes the ruptured liver to break into the chest.
The diagnostic accuracy of diagnostic peritoneal lavage for intra-abdominal hemorrhage can reach 93.4% to 100%. There are three methods:
1. Closed peritoneal lavage After emptying the bladder, the upper 1/3 of the line between the umbilicus and the pubic symphysis is punctured with a trocar at an angle of 45° (with the abdominal wall), and placed into the abdominal dialysis tube. Inject 1000 ml (10-20 ml/kg) of sterile isotonic saline or Ringer's lactate solution. Connect the outer end of the catheter to the lavage bottle during operation, raise the bottle, and use gravity to make the lavage fluid Inject into the abdominal cavity within 15 to 20 minutes, then tilt and shake the patient's abdomen to both sides. After 2 to 3 minutes, place the empty irrigation bottle at a lower position than the patient to observe whether there is blood or bloody liquid flowing back into the bottle.
2. Semi-closed peritoneal lavage with the same site as a 3mm skin incision, puncture into the abdominal cavity with a needle with a wire (usually No. 18), and placed into the abdomen.
3. Open abdominal lavage with the upper part of the 3cm skin incision, cut the peritoneum 0.5cm, observe the abdominal cavity after the tube.
Problems with peritoneal lavage: 1 non-specific, and the diagnostic criteria are different, sometimes the number of red blood cells may be visceral at (2 ~ 5) × 10l0 / L; 2 there is a false negative, especially with traumatic hernia, peritoneum Post-injury; 3 iatrogenic injury may be, 1%, including intestinal tube, bladder and intra-abdominal vascular injury; 4 operation is time-consuming, cumbersome, in recent years, B-ultrasound and CT examination have a tendency to replace peritoneal lavage, however To determine whether there is blood in the abdominal cavity, abdominal puncture is still a quick and easy method.
4. X-ray examination of the chest radiograph found that the following conditions suggest that there may be liver trauma: 1 right sacral elevation, liver shadow is unclear; 2 right pleural effusion or right pneumothorax; 3 right lower lung contusion; 4 right lower thoracic rib fracture ; 5 right under the sacral fluid or hematoma.
Abdominal plain film found that the following conditions should be highly suspected of liver rupture: 1 liver shadow increased; 2 right colon side groove expansion; 3 side abdomen has irregular strip shadow; 4 pelvic cavity with liquid retention; 5 abdominal cavity diffuse Sexual shadows; 6 metal foreign bodies remain in the upper right abdomen.
5.B-ultrasound B-ultrasound examination with its non-invasive, low price, easy to operate and has certain characteristics, has been listed as the first choice for abdominal closed injury, the emergency room is equipped with ultrasound system for emergency room B-ultrasound It is useful for repeated examination of hemodynamically unstable cases to avoid delays in rescue (Table 2).
The main manifestations of liver injury on the ultrasound image are: 1 the continuity of the liver capsule disappears, the echo at the fracture is enhanced; 2 there is no echo zone or hypoechoic zone in the subcapsular or liver parenchyma; 3 no echo zone in the abdominal cavity indicates the abdominal cavity Blood.
The sensitivity of B-ultrasound examination in emergency room to abdominal trauma was 81.5%, and the specificity was 99.7%. Shanghai Oriental Hepatobiliary Surgery Hospital performed 26 cases of closed hepatic trauma with emergency department B-ultrasound examination. The correct rate of diagnosis was 96.2% (25/26). ), only one exception of the traumatic sputum caused the ruptured left liver and stomach to be embedded in the chest, showing left pleural hemorrhage with inhomogeneous echoes.
6. CT examination for patients with difficult diagnosis and hemodynamic stability, CT examination can show: 1 hepatic subcapsular hematoma, hematoma shape is biconvex, relative density change is higher than liver parenchyma, CT value can be greater than 70 ~ 80HU, a semi-circular shadow with a blurred boundary, the liver capsule and the liver parenchyma are separated, forming a phenomenon of separation between the two. After a few days, the density of the hematoma is reduced to become almost equal to the density of the liver parenchyma, and the CT value is about 20-25HU; 2 intrahepatic hematoma, the same as the subcapsular hematoma, the liver appears in a blurred circular or oval shadow, the CT value of fresh hematoma is higher than the liver parenchyma, and then gradually reduce the density; 3 liver rupture, liver edge is not Regular cracks or defects, some are irregular linear or circular low-density areas, some are branched low-density areas, similar to dilated bile ducts, high-density blood clots are often seen in low-density areas, in recent years Come, CT examination of the diagnosis of liver injury, especially for the monitoring and observation of non-surgical treatment have important reference value.
7. Hepatic artery angiography In addition to the contrast agent, there is contrast agent spillover, and the shape of the liver changes. Intrahepatic hematoma is characterized by displacement of the branches of the liver, and the hematoma is filled with defects. The subdural hematoma shows the separation of the liver parenchyma and the capsule. In the parenchymal phase, the hepatic margin is flattened or concave, and selective hepatic angiography can not only determine the location of the laceration, but also inject embolic agents to control bleeding.
Diagnosis
Diagnosis and diagnosis of liver trauma
Diagnosis :
Open liver injury is easier to diagnose, but it is necessary to pay attention to whether there is a combined chest and abdomen injury. Closed injury with typical hemorrhagic shock and peritoneal irritation combined with a history of trauma is easy to make a diagnosis. However, for some patients with combined injuries, such as brain trauma, unconsciousness, multiple fractures with shock, elderly and frail slow response should be vigilant to avoid missed diagnosis. Mild trauma to cirrhosis or liver cancer patients can cause liver rupture, and should not be taken lightly. Whether abdominal closed injury combined with liver injury involves the problem of open surgery, so the accuracy of diagnosis is high. Diagnostic diagnosis may be assisted by abdominal puncture, abdominal lavage and other auxiliary examinations.
Differential diagnosis:
Lighter hepatic subcapsular rupture often needs to be differentiated from chest and abdominal wall contusion. The local symptoms and signs of the latter are obvious, but not accompanied by systemic and other abdominal manifestations, sometimes need to be identified in the process of close observation.
