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Chapter 29. Intra-Abdominal Diseases

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A 43-year-old man is admitted to emergency department (ED) following a motor vehicle accident. He is alert, awake, and oriented; primary survey demonstrates right upper quadrant bruises, periumbilical hematoma, and significant tenderness to palpation. There is no evidence of any other penetrating injuries. Vital signs upon admission to ED are as follows: blood pressure (BP) 107/85 mm Hg, heart rate (HR) 102 bpm, respiratory rate (RR) 25 breaths/min, and temperature of 37.5°C. Chest x-ray shows a right-sided pleural effusion. No intra-abdominal free fluid is appreciated on focused assessment with sonography for trauma (FAST) exam. Computed tomography (CT) of the abdomen with intravenous (IV) contrast shows subcapsular hematoma of approximately 40% of surface area with liver contrast blush but with no other injuries noted. His past medical history is significant for hypertension that is well controlled on metoprolol XL 50 mg daily. What is the best next management step?

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A. Surgical exploration and control of bleeding

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B. Laparoscopic exploration

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C. Liver angiography and embolization

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D. Admit to intensive care unit (ICU) for monitoring and serial abdominal exam

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E. Endoscopic retrograde cholangiopancreatography (ERCP)

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C. The patient presents with examination findings consistent with liver injury, and the CT of the abdomen with IV contrast confirms this diagnosis and shows the extent and severity of damage. The treatment approach in case of intraparenchymal hematomas without hemoperitoneum is to follow up the hematoma with serial physical exam and imaging (Table 29-1). The blush noted on CT scan is consistent with active bleeding within the liver, and active bleeding requires operative management. Methods include single pure suture, deep mattress suture, debridement, anatomic hepatectomy, hepatic arterial ligation, gauze packing, liver-coated mesh method, or embolization. The patient has a grade II liver injury (Table 29-2) that requires angiography and embolization.

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Table 29-1. Management of Liver Injury Dictated by Clinical and Computed Tomography (CT) Findings
Hemodynamically stable

Nonoperative:

  • Serial abdominal exam and CT of abdomen

  • Angiography and embolization are considered if patient is stable and CT scan shows contrast blush or evidence of ongoing bleeding

  • Grade III and above liver lacerations require embolization combined with surgical intervention

Hemodynamically unstable

Operative

  • Exploratory laparotomy; staged approach is considered for severely acidotic patients. Simple packing can be done initially. Definitive surgery done when patient is stable

  • Endoscopic retrograde cholangiopancreatography considered in management of biloma drainage; percutaneous drainage is considered for liver abscess

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Table 29-2. American Association for the Surgery of Trauma Classification of Liver Trauma
Grade Description
I

Hematoma: subcapsular, <10% surface area

Laceration: capsular tear, <1 cm parenchymal depth

II

Hematoma: ...

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