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It was a poignant moment. He was leaving home. Something that no one of his clan has ever tried. But there was no choice. The world underwater was getting overcrowded; there was dearth of food. The landmass in contrast was empty, uninhabited and ready to be explored. And to top it all, lure of food, which he was little shy to admit.He turned back, had a last look at his watery home – the ocean; and started his journey to the unknown land; on an impulse he decides to carry a memento of his past life, a bag full of ‘life-sustaining’ sea-water.Life travelled from sea to land.Millions of years ago, life-form finally crawled to land. But the bagful of sea-water still flows in our vein as ‘plasma’, the liquid component of blood. The constituent of human plasma is almost similar to seawater. Very salty, containing 135 mEq per liter of sodium.The Case70-year-old male, found unconscious at home when children came back from work. Blood Sugar normal, ECG normal, the voice of my junior resident trailed. At 3 pm in the afternoon, with another 10 patients to be seen in the OPD, he sounded more hypoglycemic himself, rather than concerned for the elderly patient. Possibility of a stroke, he mumbled.A CT scan turned out to be normal, ruling out stroke as the cause of his coma. When high tech fail. Go low tech, my Prof. had taught me, so I start asking questions to the family.The history was straight forward. Elderly gentleman, living alone during daytime. Recent loss of appetite. Had high blood pressure for which he was taking medicine and was advised to reduce salt. Recently he had sustained a leg fracture treated with a plaster cast. He was lately becoming less talkative and more sleepy.‘Check for serum sodium stat’, I told my resident.The sodium value came as a low of 110 mEq/l ; in contrast to normal of 135meq/L. We treated him with hypertonic saline infusion, followed by oral salt supplement, water restriction and over time he responded. By 3-days time he was up and telling us stories about how much better the world was when he was young.‘Hyponatremia’ (low sodium) is a not a very uncommon cause for drowsiness among the elderly.Reason for low sodium may be1. Loss of sodium and / or lack of intake – Diarrhea, vomiting etc. – Well known to everyone.2. Relative increase in body water, seen in a situation where body produces an excess of an unusual hormone called ADH (anti diuretic hormone); the illness is called SIADH. This is also called dilutional hyponatremia or ‘Water intoxication’.Never ever heard of it? This unusual situation can happen in a host of background situations, from stroke, serious infections or trauma / fractures in an elderly.SIADH (Syndrome of inappropriate ADH secretion) is treated with ‘high salt saline’ and salt supplement coupled with water restriction. We also have a new drug called Tolvaptan.Water intoxication is the other name of SIADH. It is not just getting ballooned up by drinking too much water, or not visiting the restroom.

Q: Why is a kick to the liver so debilitating?A: The liver is the largest solid abdominal organ with a relatively fixed position, which makes it prone to injury. The liver is the second most commonly injured organ in abdominal trauma, but damage to the liver is the most common cause of death after abdominal injury (see the images below). The most common cause of liver injury is blunt abdominal trauma, which is secondary to motor vehicle accidents in most instances.During triage, hemodynamically unstable patients need to undergo surgical management. Hemodynamically stable patients can undergo imaging and depending on the severity or grading (1 - 5), observation, or angioembolization versus surgical management. There is a surgical classification in the second article that determines operative management.That is why a kick to the liver can be so debilitating, possibly fatal.Liver Trauma ImagingUpdated: Oct 01, 2015Author: Ali Nawaz Khan, MBBS, FRCS, FRCP, FRCR; Chief Editor: John Karani, MBBS, FRCROverviewThe liver is the largest solid abdominal organ with a relatively fixed position, which makes it prone to injury. The liver is the second most commonly injured organ in abdominal trauma, but damage to the liver is the most common cause of death after abdominal injury (see the images below). The most common cause of liver injury is blunt abdominal trauma, which is secondary to motor vehicle accidents in most instances.Grade 1 hepatic injury in a 21-year-old man with a stabbing injury to the right upper quadrant of the abdomen. Axial, contrast-enhanced computed tomography (CT) scan demonstrates a small, crescent-shaped subcapsular and parenchymal hematoma less than 1 cm thick.Grade 1 hepatic injury in a 21-year-old man with a stabbing injury to the right upper quadrant of the abdomen. Diagram of the CT scan in the previous image.In the past, most of these injuries were treated surgically. However, surgical literature confirms that as many as 86% of liver injuries have stopped bleeding by the time surgical exploration is performed, and 67% of operations performed for blunt abdominal trauma are non therapeutic.Imaging techniques, particularly computed tomography (CT) scanning, have made a great impact on the treatment of patients with liver trauma, and use of these techniques has resulted in marked reduction in the number of patients requiring surgery and undergoing nontherapeutic operations. Almost 80% of adults and 97% of children are treated conservatively by using careful follow-up imaging studies.[1, 2]For more information, see Blunt Abdominal Trauma in Emergency Medicine, Penetrating Abdominal Trauma in Emergency Medicine, and Penetrating Abdominal Trauma.Preferred examinationPlain radiographic findings are nonspecific, but they may be useful in showing the extent of associated skeletal trauma. Contrast-enhanced CT scanning remains the examination of choice in patients with blunt abdominal trauma. [3, 4, 5, 6, 7]Radionuclide study with technetium-99m (99mTc) iminodiacetic acid (IDA) is the examination of choice in patients in whom bile leaks are suspected. Magnetic resonance imaging (MRI) has yet to find a role but can be used to monitor liver injury. Magnetic resonance cholangiopancreatography (MRCP) may be used for the diagnosis and follow-up observation of bile duct injuries.[8]Angiography is useful in localizing the site of hemorrhage and in providing an opportunity for the interventional radiologist to proceed to transcatheter embolization of bleeding sites.The original guidelines of Practice Management for Nonoperative Management of Blunt Injury to the Liver and Spleen were first issued in 2003 (Eastern Association for the Surgery of Trauma guideline). Since that time, the guidelines remain valid, supported by the accumulation of a large amount of data. Stassen et al reviewed 176 papers, of which 94 were used to create the current practice management guideline for the selective nonoperative management of blunt hepatic injury. [9]The review concluded that nonoperative management of blunt hepatic injuries currently is the treatment modality of choice in hemodynamically stable patients, irrespective of the grade of injury or patient age. However, nonoperative imaging of blunt trauma should only be considered when reliable monitoring, serial clinical evaluations, and an operating room available for urgent laparotomy are readily available. Patients who are hemodynamically unstable and have peritonitis still warrant emergent operative intervention. Ready availability of CT, angiography, percutaneous drainage, ERCP, and laparoscopy remain important adjuncts to nonoperative management of hepatic injuries. [9]The authors add that despite the explosion of literature on this topic, many questions regarding nonoperative management of blunt hepatic injuries remain without conclusive answers in the literature.[9]Limitations of techniquesPlain radiographs cannot depict liver trauma directly, and radiographic findings may be completely normal. In penetrating abdominal trauma, overall sensitivity of focused ultrasonography is 46%, and specificity is 94%. [10]Emergency ultrasonographic findings based on the demonstration of free fluid and/or parenchymal injury demonstrate the overall sensitivity of ultrasonography for detection of blunt abdominal trauma to be 72%. However, the sensitivity is higher (98%) for injuries of grade 3 or higher. However, negative ultrasonographic findings do not exclude hepatic injury.Angiographic images can fail to depict active bleeding, and false-negative or false-positive diagnoses can occur with liver trauma.RadiographyPlain radiographic findings are nonspecific, but they are useful in evaluating rib and spinal injuries in patients with blunt abdominal trauma. Fractures of the right lower ribs should suggest the possibility of underlying liver injury. Pneumoperitoneum, major diaphragmatic injury, gross organ displacement, and metallic foreign bodies may be identified. [11]Degree of confidencePlain radiographs are sensitive and specific in demonstrating skeletal injuries and usually are the first radiologic examination performed in patients in whom liver trauma is suspected. Radiographs may initially depict opaque foreign bodies, such as bullets or shrapnel.False positives/negativesBecause plain radiography is performed in a traumatized patient, an optimal-quality radiograph is not always possible. Fractures and a pneumoperitoneum may be missed.Computed TomographyCT scanning, particularly contrast-enhanced CT scanning, is accurate in localizing the site and extent of liver injuries and associated trauma, providing vital information for treatment in patients. [3, 4]Spiral CT scanning is the preferred scanning technique, if available. Multidetector-row CT scanning offers the further advantages of fast scanning times (allowing scanning during specific phases of intravenous contrast enhancement) and the acquisition of thin sections over a large area (allowing high-quality multiplanar reconstruction).[12]CT scanning without intravenous contrast enhancement is of limited value in hepatic trauma, but it can be useful in identifying or following up a hemoperitoneum.CT scans can be used to monitor healing. Trauma to the liver may result in subcapsular or intrahepatic hematoma, contusion, vascular injury, or biliary disruption. [13]CT scan criteria for staging liver trauma based on the AAST liver injury scale include the following:Grade 1 - Subcapsular hematoma less than 1 cm in maximal thickness, capsular avulsion, superficial parenchymal laceration less than 1 cm deep, and isolated periportal blood tracking (see the images below)Grade 1 hepatic injury in a 21-year-old man with a stabbing injury to the right upper quadrant of the abdomen. Axial, contrast-enhanced computed tomography (CT) scan demonstrates a small, crescent-shaped subcapsular and parenchymal hematoma less than 1 cm thick.Grade 1 hepatic injury in a 21-year-old man with a stabbing injury to the right upper quadrant of the abdomen. Diagram of the CT scan in the previous image.Grade 2 - Parenchymal laceration 1-3 cm deep and parenchymal/subcapsular hematomas 1-3 cm thick (see the images below) A 20-year-old man with systemic lupus erythematosus presented with grade 2 liver injury after minor blunt abdominal trauma. Nonenhanced axial CT scan at the level of the hepatic veins shows a subcapsular hematoma 3 cm thick.A 20-year-old man with systemic lupus erythematosus presented with grade 2 liver injury after minor blunt abdominal trauma. Diagram of the CT scan in the previous image.A 20-year-old man with systemic lupus erythematosus presented with grade 2 liver injury after minor blunt abdominal trauma (same patient as in the previous 2 images). Axial CT image through the inferior aspect of the right lobe of the liver demonstrates multiple low-attenuation lesions in the liver consistent with parenchymal contusion.A 20-year-old man with systemic lupus erythematosus presented with grade 2 liver injury after minor blunt abdominal trauma (same patient as in the previous 3 images). Diagram of the CT scan in the previous image.Grade 3 - Parenchymal laceration more than 3 cm deep and parenchymal or subcapsular hematoma more than 3 cm in diameter (see the images below)Grade 3 liver injury in a 22-year-old woman after blunt abdominal trauma. Contrast-enhanced axial CT scan through the upper abdomen shows a 4-cm-thick subcapsular hematoma associated with parenchymal hematoma and laceration in segments 6 and 7 of the right lobe of the liver. Free fluid is seen around the spleen and left lobe of the liver consistent with hemoperitoneum.Grade 3 liver injury in a 22-year-old woman after blunt abdominal trauma. Diagram of the CT scan in the previous image.Grade 4 - Parenchymal/subcapsular hematoma more than 10 cm in diameter, lobar destruction, or devascularization (see the images below)Image obtained in a 35-year-old male bouncer after blunt abdominal injury. Nonenhanced axial CT scan of the abdomen demonstrates a large subcapsular hematoma measuring more than 10 cm. The high-attenuating areas within the lesion represent clotted blood. The injury was classified as a grade 4 liver injury.Image in a 35-year-old male bouncer after blunt abdominal injury (same patient as in the previous image). Diagram of the CT scan in Image above.Contrast-enhanced axial CT scan in a 39-year-old man with a grade 4 liver injury shows a large parenchymal hematoma in segments 6 and 7 of the liver with evidence of an active bleed. Note the capsular laceration and large hemoperitoneum.Diagram of the CT scan in Image above in a 39-year-old man with a grade 4 liver injury shows a large parenchymal hematoma in segments 6 and 7 of the liver with evidence of an active bleed.Multisegment infarct (segments 2, 3, 4a, and 4b) in a 40-year-old man who was in a motor vehicle accident and underwent emergency segmental resection of the right lobe. Note the sharply demarcated wedge-shaped area of infarction; hence, the classification as grade 4.Multisegment infarct (segments 2, 3, 4a, and 4b) in a 40-year-old man who was in a motor vehicle accident and underwent emergency segmental resection of the right lobe. Diagram of the CT scan in the previous image.Grade 5 - Global destruction or devascularization of the liver (see the images below)Grade 5 injury in a 36-year-old man who was involved in a motor vehicle accident demonstrates global injury to the liver. Bleeding from the liver was controlled by using Gelfoam.Grade 5 injury in a 36-year-old man who was involved in a motor vehicle accident (same patient as in the 2 previous images). Axial CT scan shows a hematoma around the right kidney and inferior vena cava consistent with renal and inferior vena cava injury.Grade 5 injury in a 36-year-old man who was involved in a motor vehicle accident (same patient as in the previous 3 images). Diagram of the CT scan in the previous image.Grade 6 - Hepatic avulsionWSES classification and guidelines for liver traumaThe severity of liver injuries has been universally classified according to the American Association for the Surgery of Trauma (AAST) grading scale. In determining the optimal treatment strategy, however, the haemodynamic status and associated injuries should be considered. Thus the management of liver trauma is ultimately based on the anatomy of the injury and the physiology of the patient. This paper presents the World Society of Emergency Surgery (WSES) classification of liver trauma and the management Guidelines.Subcapsular hematomaSubcapsular hematoma is usually seen in a lenticular configuration; most subcapsular hematomas are anterolateral to the right lobe of the liver. Subcapsular hematomas cause direct compression and deformity of the shape of the underlying liver.On nonenhanced CT scans, the liver appears hyperattenuating compared with a subcapsular hematoma. [14]On enhanced CT scans, a subcapsular hematoma appears as a low-attenuating, lenticular collection between the liver capsule and the enhancing liver parenchyma.Unless bleeding recurs, attenuation of the subcapsular hematoma decreases with time. Subcapsular hematomas resolve within 6-8 weeks.Intraparenchymal hematomasOn contrast-enhanced CT scans, acute hematomas appear as irregular, high-attenuation areas, which represent clotted blood, surrounded by low-attenuating unclotted blood or bile. Over time, the attenuation of the hematoma is reduced, and the hematoma eventually forms a well-defined serous fluid collection that may expand slightly. A focal, intrahepatic, hyperattenuating area with attenuation of 80-350 HU may represent an active hemorrhage or pseudoaneurysm.Focal or diffuse periportal low attenuation is believed to be secondary to tracking of blood around the portal vessels, although other possibilities include bile leaks, edema, and dilated periportal lymphatics resulting from increased central venous pressure or injury to the lymphatics.A low-attenuating periportal collar is seen in children with nonhepatic blunt abdominal trauma and also in the absence of intra-abdominal injury. Thus, without other ancillary findings within the liver, the presence of a low-attenuating periportal collar is not indicative of hepatic injury. However, the presence of this sign in documented abdominal trauma correlates with the severity of trauma, physiologic instability, and a higher mortality rate.CT scan findings in approximately 25% of children with blunt abdominal trauma show periportal low attenuation. That only 40% of these children have evidence of liver injury has been shown.LacerationLaceration of the liver appears as a nonenhancing linear or branching structure, usually at the liver periphery. Acute lacerations have a sharp or jagged margin, but with time, lacerations may enlarge, and the margins may develop rolled edges.Multiple parallel lacerations occur as result of compressive forces (bear claw lacerations). Lacerations may communicate with hepatic vessels and/or biliary radicles.Vascular injuriesInjuries to the major hepatic veins and the retrohepatic inferior vena cava are uncommon after blunt abdominal trauma.Retrohepatic vena caval injuries are suggested on CT scans when lacerations extend into the major hepatic veins and the inferior vena cava or when profuse retrohepatic hemorrhage extends into the lesser sac or near the diaphragm.Perihilar liver tissue may become partially devascularized by a deep laceration or complete avulsion of the dual hepatic blood supply. These devascularized areas of the liver appear as wedge-shaped regions extending toward the liver periphery, and they fail to enhance after the administration of contrast material.Pseudoaneurysms are better depicted by using spiral or multisection CT scanning because of the ability to image during peak contrast enhancement.Acute hemorrhageAcute, intrahepatic hemorrhage is seen as irregular areas of contrast agent extravasation.Measurement of attenuation values is useful in differentiating extravasated contrast from hematoma. Extravasated contrast material has an attenuation value of 85-350 HU (mean, 132 HU), whereas hemorrhage has an attenuation value of 40-70 HU (mean, 51 HU).CT scans can be useful in depicting recurrent bleeding after surgery or radiologic intervention.Gallbladder injuryGallbladder injury is uncommon, occurring in 2-8% patients with blunt liver trauma. Prior to the availability of CT scanning and ultrasonography, gallbladder injuries were rarely diagnosed before surgery.[15]CT findings in gallbladder injuries include ill-defined or irregular wall contour, pericholecystic or subserosal fluid, collapsed gallbladder, wall thickening, intraluminal blood, free intraluminal mucosal flap, contrast enhancement of the gallbladder wall or mucosa, free intraperitoneal fluid iso-attenuating with bile, mass effect on the duodenum, and displacement of the gallbladder toward the midline.Biloma and bile peritonitisAs a result of the slow rate of leaking, a biloma may take weeks or months to develop after trauma; hence, it usually is diagnosed by using follow-up scans. CT scan findings of a posttraumatic biloma demonstrate a cystic structure of low attenuation in or around the liver. Bilomas may contain debris or septa.Bile peritonitis is an uncommon complication of blunt liver trauma. CT scan findings of bile peritonitis include persistence or increasing amounts of low-attenuating, free peritoneal fluid and thickening of a peritoneum that shows evidence of enhancement.Degree of confidenceCT scanning is the mainstay of diagnosis of hepatic injuries following blunt trauma; initial CT scan findings help in determining the type of treatment required. With the use of high-speed, spiral CT scans, predicting the necessity of operative treatment or angiography is possible in patients with blunt hepatic injury before deterioration of their hemodynamic state.A finding of pooled contrast material within the peritoneal cavity indicates active and massive bleeding; patients with this finding may require emergency surgery. [16]Intrahepatic pooling of contrast material with an intact liver capsule usually indicates a self-limiting hemorrhage; most patients with this finding can be treated conservatively.CT scanning has been proven to be extremely useful in helping to make therapeutic decisions in hepatic trauma and in helping to reduce laparotomy rates in as many as 70% patients at the time of initial evaluation.False positives/negativesFalse-positive errors in the diagnosis of liver injury with CT scans may occur as a result of beam-hardening artifacts from adjacent ribs, which can mimic contusion or hematoma. An air-contrast level within the stomach in a patient with a nasogastric tube can produce streak artifacts throughout the left lobe of the liver; these may mimic intrahepatic lacerations and/or hemorrhage. The nature of these artifacts can be confirmed if the patient is scanned in a decubitus position.False-negative findings may occur in the setting of a fatty liver only when contrast-enhanced CT scans are obtained. On these images, the enhanced fatty liver may become iso-attenuating relative to the laceration or hematoma. In this situation, a nonenhanced CT scan may provide useful information regarding hepatic injury. Focal fatty infiltration may also mimic hepatic hematoma, laceration, or infarction. Hepatic lacerations with a branching pattern can mimic nonopacified portal or hepatic veins or dilated intrahepatic bile ducts. Careful evaluation of all branching intrahepatic structures is important, and the diagnosis is made with serial images to differentiate the various structures.Small amounts of free intraperitoneal blood or fluid in the perihepatic space may mimic a subcapsular hematoma; however, these fluid collections usually do not compress the liver parenchyma. CT scans do not always help in predicting which patients require laparotomy. [17]Hematomas or hemorrhage within the liver can occur with a nontraumatic etiology.In the evaluation of recurrent hepatic bleeding, particularly after an angiographic intervention, nonenhanced and enhanced scans are important to distinguish extravasated contrast material during angiography from recurrent, ongoing hemorrhage. Other hepatic lesions that may mimic active bleeding on CT scans include calcified liver masses and hemangiomas.Magnetic Resonance ImagingMRI has a limited role in the evaluation of blunt abdominal trauma, and it has no advantage over CT scanning. Theoretically, MRI can be used in follow-up monitoring of patients with blunt abdominal trauma, and the modality may be useful in young and pregnant women with abdominal trauma in whom the radiation dose is a concern. [18]MRCP has been used in the assessment of pancreatic duct trauma and its sequelae, and it can be used to image biliary trauma. [8]Another potential use of MRI is in patients with renal failure and in patients who are allergic to radiographic contrast medium.Degree of confidenceMRI offers no significant advantage over CT scanning for routine evaluation of acute abdominal trauma. Experience is insufficient for assessing the value of the above-mentioned special circumstances.False positives/negativesSufficient experience has not been gained in the use of MRI to establish false-positive and false-negative findings.UltrasonographyUltrasonograms can demonstrate a number of traumatic lesions, such as hematomas, contusions, bilomas, and hemoperitoneum. [19, 20]For ultrasonograms of liver trauma, see the images below.Sonogram of the liver in a 62-year-old woman with a history of recent liver biopsy. The scan shows a loculated anechoic collection in the liver; whether this finding represents a biloma or a hematoma is not clear on this scan.Abdominal sonogram in a 35-year-old male bouncer after blunt abdominal injury shows a crescent-shaped hyperechoic collection along the right lateral aspect of the liver consistent with subcapsular hematoma.Hepatic hematomas are grouped into 3 categories, as follows:Rupture into the liver and its capsuleSeparation of the capsule by a subcapsular hematomaCentral hepatic rupturesA subcapsular hematoma usually appears as a curvilinear fluid collection; its echogenicity varies with age. Initially, hematomas are anechoic, becoming progressively more echogenic over the course of 24 hours. With the passage of time, echogenicity of the hematoma once again begins to decrease, and within 4-5 days, the hematoma becomes hypo-echoic or anechoic.Septa and internal echoes often develop within the hemorrhagic collection by 1-4 weeks. Appearances of hepatic laceration change with time. Lacerations appear slightly echogenic, becoming hypoechoic or cystic when scanned days after the injury.Similar to hematomas, contusions usually are hypoechoic initially, becoming transiently hyperechoic and then hypoechoic. The most common ultrasonographic pattern observed with liver parenchymal injuries is a discrete hyperechoic area; however, a diffuse hyperechoic and occasionally a discrete hypoechoic pattern may be observed. [14,19]An echogenic clot often is seen surrounding the liver, and hypoechoic fluid may be observed in other parts of the abdomen.Bilomas appear as rounded or ellipsoid, anechoic, loculated structures that are fairly well defined in close proximity to the liver and bile duct. Diaphragmatic ruptures appear as a discontinuous line of echoes.A number of studies have suggested that ultrasonography can replace the invasive procedure of peritoneal lavage in the evaluation of blunt abdominal trauma.Degree of confidenceFocused assessment performed by using ultrasonography in patients with liver trauma is still investigational for evaluation of blunt and penetrating abdominal trauma. [20]The primary advantage is immediate availability in emergency departments. Some centers use ultrasonography as the initial examination. Patients who are unstable and have a large amount of fluid detected on ultrasonograms are immediately transported for surgery. In addition, patients at these centers who are stable and who have a large amount of intra-abdominal fluid also may be immediately treated with surgery.An alternative approach is followed in other centers. If ultrasonographic findings are positive for intra-abdominal fluid, CT scanning is the next step. If fluid is not demonstrated on abdominal ultrasonograms, the patient is observed for 12 hours; however, if abdominal pain persists, the patient undergoes CT scanning.Ultrasonography is the initial examination of choice in the pediatric age group because of the modality's nonionizing and noninvasive nature. Ultrasonography is particularly useful in imaging neonates who are ill and in whom the clinical condition is too unstable to allow transport to a CT scanning facility but who may have a hepatic hematoma after a traumatic delivery or resuscitative efforts.In a neonate with a decreasing hematocrit level and increasing abdominal distension, ultrasonography may rapidly help in confirming a diagnosis of liver trauma. Because most children with hepatic trauma are treated conservatively, most children can be monitored by using ultrasonography.Ultrasonography has several advantages over peritoneal lavage in the diagnosis of blunt abdominal trauma. Ultrasonography is a noninvasive procedure that is readily available at the patient's bedside and is less expensive to perform than is peritoneal lavage. However, although ultrasonography may be useful in most patients with blunt abdominal trauma, pitfalls remain.False positives/negativesInjury to the liver, especially at the dome or lateral segment of the left lobe of the liver, can easily be missed with ultrasonography, particularly in the presence of ileus or when pain makes the examination difficult. The sensitivity of ultrasonography in the detection of free abdominal fluid associated with bowel or mesenteric injury has been reported as only 44%. Blunt abdominal injury may involve organs other than the liver, and these injuries must be detected reliably.Ultrasonograms may not directly depict injuries to the bowel, mesentery, pancreas, diaphragm, adrenal gland, and bone. Ultrasonography is probably limited in the detection of many vascular injuries as well. A hepatic laceration may be initially difficult to detect, but it may become obvious with the passage of time.Hepatic hemorrhage may occur as a result of causes other than trauma, including sickle cell anemia, liver tumors, coagulopathies, organ phosphate toxicity, and collagen vascular disease. It may also occur in patients receiving long-term hemodialysis. Hepatic hemorrhage and rupture may occur in eclampsia, pre-eclampsia during the third trimester of pregnancy, HELLP syndrome (hemolysis, elevated liver enzymes, low platelets), hepatic adenoma, and hepatocellular carcinoma.Nuclear ImagingPrior to the widespread availability of CT scanning, technetium-99m (99m Tc) sulfur colloid or 99m Tc-labeled denatured red blood cell studies were widely used in the evaluation of patients with blunt hepatic and splenic trauma. The primary limitations of radionuclides are the nonspecific findings and an inability to evaluate other intraperitoneal and retroperitoneal organs. Despite the disadvantages, radionuclide techniques can offer an important imaging alternative in patients in whom CT scanning cannot be performed, such as those patients in whom the use of intravenous and oral contrast is contraindicated, those who cannot hold their breath, and those who have metallic objects or surgical clips in the abdominal cavity (see the images below).A 62-year-old woman with a history of recent liver biopsy. Technetium-99m iminodiacetic acid (IDA) scan obtained immediately after the injection of the radioisotope shows a large filling defect in the liver, which showed subsequent filling in the 4-hour image consistent with biloma.Technetium-99m iminodiacetic acid (IDA) scan in a 30-year-old man who sustained liver injury in a motor vehicle accident. The scan was obtained 1 month later and shows extravasation of the isotope from the biliary tract; this is consistent with a bile leak. Note the relative photon deficiency of the right lobe, which is due to liver contusion.Patients who have documented evidence of hepatic or splenic trauma can be monitored noninvasively by using 99m Tc sulfur colloid scanning. Most patients with liver trauma show complete or partial resolution of the colloid defects over a period of 3-6 months. However, defects within the spleen may persist indefinitely and do not necessarily indicate a poor prognosis. Whether defects in the liver have similar connotations is uncertain.After splenic rupture, splenic tissue can become implanted in the peritoneal or intrathoracic cavities (splenosis). Splenosis may be difficult to differentiate from other masses, such as lymphadenopathy, on subsequent scans obtained by using cross-sectional imaging, particularly when scans are performed remote in time from the injury. Uptake with 99m Tc sulfur colloid or 99m Tc-labeled denatured red cells provides a tissue-specific diagnosis of ectopic splenic tissue.Labeled red cells may be used to detect the site of active intraperitoneal or retroperitoneal hemorrhage, although quantitating the size of the hemorrhage is difficult using this technique.Bile duct and/or gallbladder injuries occur in 5% of patients with blunt abdominal trauma. Moreover, biliary injuries may not be identified pre-operatively or may remain unidentified for weeks or months after trauma.Although CT scanning remains the examination of choice in the evaluation of liver trauma, the procedure of choice to evaluate bile leaks is 99m Tc iminodiacetic acid (IDA) scanning. CT scanning and ultrasonography can help to detect intra-abdominal fluid, but differentiation between loculated ascitic fluid and hematoma, abscess, and biloma may not be always possible. Scanning for 99m Tc IDA uptake usually is performed as a dynamic study immediately after the injection of the radionuclide. The angiographic phase can provide important information regarding vascular injuries and associated renal injury, which may subsequently be missed on static scans.Following the dynamic study, a 20-min static scan of the liver is obtained in several planes; in appropriate circumstances, scans can be obtained for as long as 24 hours.Bile leaks are demonstrated as extravasated activity shortly after administration of the radionuclide. Bilomas are demonstrated initially as a photon-deficient mass that shows activity on delayed scans. In the detection of bilomas, delayed images are essential (2-24 h); otherwise bilomas may be missed.Degree of confidenceIn patients with blunt trauma, there is an inability to evaluate other sites of abdominal injury and to quantitate intraperitoneal and retroperitoneal hemorrhage. However, in patients in whom a bile leak or biloma is suspected, 99m Tc IDA uptake imaging is the examination of choice; this provides a noninvasive technique for arriving at a specific diagnosis.False positives/negativesFocal defects identified with 99m Tc sulfur colloid scanning or in the angiographic/hepatic phase of 99m Tc IDA scanning may not be related to the trauma; these defects may instead represent simple liver cysts, granulomas, pseudotumors, abscesses, or tumors unrelated to trauma. If delayed scans are not performed, bilomas and bile leaks may be missed using 99m Tc IDA scans. Delayed imaging not only provides time for the activity to accumulate within the biloma but also allows clearing of the isotope from the liver, increasing the target-to-background ratio of activity.AngiographyMost patients with liver trauma who present to the emergency department in shock have positive results after peritoneal lavage and require immediate laparotomy to control hemorrhage. Angiography has no role in the evaluation of these patients. However, patients with less severe trauma may be difficult to evaluate at clinical examination and at laparotomy.If the patient is stable, cross-sectional imaging may provide sufficient detail to treat the patient conservatively. A dynamic angiographic study may demonstrate the site of active bleeding, providing an opportunity for transcatheter embolization, which may be the only treatment required (see the images below).Selective celiac arteriogram of a grade 1 hepatic injury in a 21-year-old man with a stabbing injury to the right upper quadrant of the abdomen. The image shows a focal area of hemorrhage in the right lobe of the liver (arrow) due to the stabbing injury. The well-demarcated filling defect seen in the lateral aspect of the right lobe of the liver is due to compression of normal liver parenchyma by the subcapsular hematoma.Postembolization selective arteriogram of a grade 1 hepatic injury in a 21-year-old man with a stabbing injury to the right upper quadrant of the abdomen (same patient as in the previous image). The image shows cessation of the bleeding in the right lobe of the liver.A 20-year-old man with systemic lupus erythematosus presented with grade 2 liver injury after minor blunt abdominal trauma. Selective celiac artery arteriogram shows multiple microaneurysms due to systemic lupus erythematosus. Note the parenchymal filling defects due to contusion and medial displacement of the right liver margin due to subcapsular hematoma.Liver contusionAngiographic findings in patients with liver contusion include the following:Stretching and elongation of arterial branches around an avascular mass may be observed.Delay in hepatic blood flow to the involved segments may occur.A transient attenuation difference in uninvolved segments may be depicted.Mottled accumulation of contrast material in the parenchymal phase may be noted.The portal venous phase may confirm a parenchymal defect.Peripheral portal venous filling may be unusually well demonstrated in the presence of contusions.Liver lacerationsAngiographic findings in patients with liver lacerations include the following:Arterial collaterals may bypass arterial occlusions.Contrast material extravasation may occur.Discrete lacerations may appear as linear or complex lucent defects.Intrahepatic hematomas may appear as poorly defined lucent defects.Arterioportal fistulas may be obvious.Contrast material may pass into the biliary tree, identifying the site of hemobilia.Subcapsular hematomaAngiographic findings in patients with subcapsular hematoma include the following:Subcapsular hematomas compress normal parenchyma and may appear as sharply defined, lucent defects against the increased contrast accumulation in the compressed parenchyma.Arterial displacement may be seen.Contrast material extravasation may occur.High-velocity bullet injuriesAngiographic findings in patients with high-velocity bullet injuries include the following:High-velocity bullets tend to cause burst injuries with distant contusions and parenchymal disruption.Occasionally, these injuries are associated with aortic and renal injuries.All of the angiographic findings of blunt liver trauma can be seen in this group of patients.Low-velocity penetrating injuries (stab wounds, liver biopsy, and biliary drainage TIPS procedure)Angiographic findings in patients with low-velocity penetrating injuries include the following:Arterial aneurysms and arterial pseudo-aneurysmsArteriovenous fistulasHematomasDegree of confidenceEvaluating the extent of liver injury at surgery may be difficult; in fact, identifying the lesion within the liver may occasionally be impossible. Emergency hepatic angiography should be performed if at all feasible, because it not only documents the injury and helps to evaluate complications, such as pseudo-aneurysms, subcapsular hematoma, or hemobilia, it also provides access for transcatheter embolization.False positives/negativesAlthough angiography is useful in selected patients, false-positive and false-negative results occur in patients with hepatic trauma.Liver rupture may be spontaneous or may occur as result of liver tumors, HELLP syndrome, simple cysts, amebic abscess, and hydatid cysts. Intrahepatic arterial aneurysms may be congenital or may be related to vasculitides.SECTIONS Liver Trauma ImagingOverviewRadiographyComputed TomographyMagnetic Resonance ImagingUltrasonographyNuclear ImagingAngiographyShow AllJennings GR, Poole GV, Yates NL, et al. Has nonoperative management of solid visceral injuries adversely affected resident operative experience?. Am Surg. 2001 Jun. 67(6):597-600. 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Computed tomography arterial portography for assessment of portal vein injury after blunt hepatic trauma. Diagn Interv Radiol. 2015 Sep-Oct. 21 (5):361-7. [Medline].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 Jun. 48(6):1001-7. [Medline].[Guideline] Stassen NA, Bhullar I, Cheng JD, et al. Nonoperative management of blunt hepatic injury: an Eastern Association for the Surgery of Trauma practice management guideline. J Trauma Acute Care Surg. 2012 Nov. 73(5 Suppl 4):S288-93. [Medline].Udobi KF, Rodriguez A, Chiu WC, et al. Role of ultrasonography in penetrating abdominal trauma: a prospective clinical study. J Trauma. 2001 Mar. 50(3):475-9. [Medline].Walter KD. Radiographic evaluation of the patient with sport-related abdominal trauma. Curr Sports Med Rep. 2007 Apr. 6(2):115-9. [Medline].Wong YC, Wang LJ, Fang JF, et al. Multidetector-row computed tomography (CT) of blunt pancreatic injuries: can contrast-enhanced multiphasic CT detect pancreatic duct injuries?. J Trauma. 2008 Mar. 64(3):666-72. [Medline].Poletti PA, Mirvis SE, Shanmuganathan K, et al. CT criteria for management of blunt liver trauma: correlation with angiographic and surgical findings. Radiology. 2000 Aug. 216(2):418-27. [Medline]. [Full Text].Casillas VJ, Amendola MA, Gascue A, et al. Imaging of nontraumatic hemorrhagic hepatic lesions. Radiographics. 2000 Mar-Apr. 20(2):367-78. [Medline]. [Full Text].Sondenaa K, Horn A, Nedrebo T. Diagnosis of blunt trauma to the gallbladder and bile ducts. Eur J Surg. 2000 Nov. 166(11):903-7. [Medline].Fang JF, Chen RJ, Wong YC, et al. Classification and treatment of pooling of contrast material on computed tomographic scan of blunt hepatic trauma. J Trauma. 2000 Dec. 49(6):1083-8. [Medline].Knudson MM, Maull KI. Nonoperative management of solid organ injuries. Past, present, and future. Surg Clin North Am. 1999 Dec. 79(6):1357-71. [Medline].Yamamoto F, Pu Y, Igimi H, et al. MR imaging of traumatic hepatic laceration: evaluation and course of healing after surgery. Abdom Imaging. 1993. 18(3):253-7. [Medline].Richards JR, McGahan JP, Pali MJ, et al. Sonographic detection of blunt hepatic trauma: hemoperitoneum and parenchymal patterns of injury. J Trauma. 1999 Dec. 47(6):1092-7. [Medline].Ma OJ, Kefer MP. Ultrasound detection of free intraperitoneal fluid associated with hepatic and splenic injuries. South Med J. 2001 Jan. 94(1):54-7. [Medline].World Journal of Emergency SurgeryMainMenuHOMEABOUTARTICLESSUBMISSION GUIDELINESWSES classification and guidelines for liver traumaWorld Journal of Emergency Surgery 2016 11:50DOI: 10.1186/s13017-016-0105-2Published: 10 October 2016AbstractThe severity of liver injuries has been universally classified according to the American Association for the Surgery of Trauma (AAST) grading scale. In determining the optimal treatment strategy, however, the haemodynamic status and associated injuries should be considered. Thus the management of liver trauma is ultimately based on the anatomy of the injury and the physiology of the patient. This paper presents the World Society of Emergency Surgery (WSES) classification of liver trauma and the management Guidelines.KeywordsLiver trauma Minor Moderate Severe Classification Guidelines Surgery Hemorrage Operative management Non-operative managementBackgroundThe severity of liver injuries is universally classified according to the American Association for the Surgery of Trauma (AAST) grading scale (Table 1) [1]. The majority of patients admitted for liver injuries have grade I, II or III and are successfully treated with nonoperative management (NOM). In contrast, almost two-thirds of grade IV or V injuries require laparotomy (operative management, OM) [2]. However in many cases there is no correlation between AAST grade and patient physiologic status. Moreover the management of liver trauma has markedly changed through the last three decades with a significant improvement in outcomes, especially in blunt trauma, due to improvements in diagnostic and therapeutic tools [3, 4, 5]. In determining the optimal treatment strategy, the AAST classification should be supplemented by hemodynamic status and associated injuries. The anatomical description of liver lesions is fundamental in the management algorithm but not definitive. In fact, in clinical practice the decision whether patients need to be managed operatively or undergo NOM is based mainly on the clinical conditions and the associated injuries, and less on the AAST liver injury grade. Moreover, in some situations patients conditions lead to an emergent transfer to the operating room (OR) without the opportunity to define the grade of liver lesions before the surgical exploration; thus confirming the primary importance of the patient’s overall clinical condition. Utimately, the management of trauma requires an assessment of the anatomical injury and its physiologic effects.AAST Liver Trauma ClassificationGradeInjury typeInjury descriptionMethodsThe discussion of the present guidelines started in 2011 during the WSES World Congress in Bergamo (Italy). From that first discussion, through the Delphi process came the published position paper [6]. A group of experts in the field coordinated by a central coordinator was contacted to express their evidence-based opinion on several issues about the liver trauma management differentiated into blunt and penetrating trauma and evaluating the conservative and operative management for both.The central coordinator assembled the different answers derived from the first round and drafted the first version that was subsequently revised by each member of the expert group separately in the second round. The definitive version about which the agreement was reached consisted in the position paper published in 2013 [6].In July 2013 the position paper was discussed during the WSES World Congress in Jerusalem (Israel) and then a subsequent round of consultation among a group of experts evaluated the associated WSES classification and the new evidence based improvements. Once reached the agreement between the first experts group, another round among a larger experts group lead to the present form of the WSES classification and guidelines of liver trauma to which all the experts agreed. Levels of evidence have been evaluated in agreement with the Oxford guidelines.WSES classificationThe WSES position paper suggested dividing hepatic traumatic lesions into minor (grade I, II), moderate (grade III) and major/severe (grade IV, V, VI) [6]. This classification has not previously been clearly defined by the literature. Frequently low-grade AAST lesions (i.e. grade I-III) are considered as minor or moderate and treated with NOM [7, 8]. However some patients with high-grade lesions (i.e. grade IV-V laceration with parenchymal disruption involving more than 75 % of the hepatic lobe or more than 3 Couinaud segments within a single lobe) may be hemodynamically stable and successfully treated nonoperatively [2]. On the other hand, “minor” lesions associated with hemodynamic instability often must be treated with OM. This demonstrates that the classification of liver injuries into minor and major must consider not only the anatomic AAST classification but more importantly, the hemodynamic status and the associated injuries.The Advanced Trauma Life Support (ATLS) definition considers as “unstable” the patient with: blood pressure <90 mmHg and heart rate >120 bpm, with evidence of skin vasoconstriction (cool, clammy, decreased capillary refill), altered level of consciousness and/or shortness of breath [9].Recommendations for non operative management (NOM) in blunt liver trauma (BLT)Blunt trauma patients with hemodynamic stability and absence of other internal injuries requiring surgery, should undergo an initial attempt of NOM irrespective of injury grade (GoR 2 A).NOM is contraindicated in the setting of hemodynamic instability or peritonitis (GoR 2 A).NOM of moderate or severe liver injuries should be considered only in an environment that provides capability for patient intensive monitoring, angiography, an immediately available OR and immediate access to blood and blood product (GoR 2 A).In patients being considered for NOM, CT-scan with intravenous contrast should be performed to define the anatomic liver injury and identify associated injuries (GoR 2 A).Angiography with embolization may be considered the first-line intervention in patients with hemodynamic stability and arterial blush on CT-scan (GoR 2 B).In hemodynamically stable blunt trauma patients without other associated injuries requiring OM, NOM is considered the standard of care [10, 11, 12]. In case of hemodynamic instability or peritonitis NOM is contraindicated [7, 11, 13].The requirements to attempt NOM of moderate and severe injuries are the capability to make a diagnosis of the severity of liver injuries, and to provide intensive management (continuous clinical monitoring, serial hemoglobin monitoring, and around-the-clock availability of CT-scan, angiography, OR, and blood and blood products) [14, 15, 16, 17, 18, 19]. No evidence exists at present to define the optimal monitoring type and duration.In patients with ongoing resuscitative needs, the angioembolization is considered as an “extension” of resuscitation. However with the aim to reduce the need for transfusions and surgery, angioembolization can be applied safely but generally only in selected centers [13, 20, 21]. If required it can be safely repeated. Positive results associated with its early use have been published [22, 23].In blunt hepatic trauma, particularly after high-grade injury, complications occur in 12–14 % of patients [13, 24]. Diagnostic tools for complications after NOM include: clinical examination, blood tests, ultrasound and CT-scan. Although routine follow-up with CT-scan is not necessary, [2, 13, 24] in the presence of abnormal inflammatory response, abdominal pain, fever, jaundice or drop of hemoglobin level, CT-scan is recommended [13]. Bleeding, abdominal compartment syndrome, infections (abscesses and other infections), biliary complications (bile leak, hemobilia, bilioma, biliary peritonitis, biliary fistula) and liver necrosis are the most frequent complications associated with NOM [14, 24]. Ultrasound is useful in the assessment of bile leak/biloma in grade IV-V injuries, especially with a central laceration.Re-bleeding or secondary hemorrhage are frequent (as in the rupture of a subcapsular hematoma or a pseudo-aneurysm) [13, 24]. In the majority of cases (69 %), “late” bleeding can be treated non-operatively [13, 24]. Post-traumatic hepatic artery pseudo-aneurysms are rare and they can usually be managed with selective embolization [6, 25].Biliary complications can occur in 30 % of cases. Endoscopic retrograde cholangio-pancreatography (ERCP) and eventual stenting, percutaneous drainage and surgical intervention (open or laparoscopic) are all effective ways to manage biliary complications [13]. In presence of intrahepatic bilio-venous fistula (frequent associated with bilemia) ERCP represents an effective tool [26].CT-scan or ultrasound-guided drainage are both effective in managing peri-hepatic abscesses (incidence 0–7 %) [13, 22, 24]. In presence of necrosis and devascularization of hepatic segments surgical management would be indicated [6, 24]. Hemobilia is uncommon and frequently associated with pseudo-aneurysm [2, 6, 24]. In hemodynamically stable and non-septic patients embolization is safe and could be considered as the first approach; otherwise surgical management is mandatory [6, 24].Lastly, the liver compartment syndrome is rare and has been described in some case reports as a consequence of large sub-capsular hematomas. Decompression by percutaneous drainage or by laparoscopy has been described [24, 27].No standard follow-up and monitoring protocol exist to evaluate patients with NOM liver injuries [6]. Serial clinical evaluation and hemoglobin measurement are considered the pillars in evaluating patients undergone to NOM [10]. Abdominal ultrasound could help in managing non-operatively managed liver trauma patients.Recommendations for NOM in penetrating liver trauma (PLT)NOM in penetrating liver trauma could be considered only in case of hemodynamic stability and absence of: peritonitis, significant free air, localized thickened bowel wall, evisceration, impalement (GoR 2 A).NOM in penetrating liver trauma should be considered only in an environment that provides capability for patient intensive monitoring, angiography, an immediately available OR and immediate access to blood and blood product (GoR 2 A).CT-scan with intravenous contrast should be always performed to identify penetrating liver injuries suitable for NOM (GoR 2 A).Serial clinical evaluations (physical exams and laboratory testing) must be performed to detect a change in clinical status during NOM (GoR 2 A).Angioembolisation is to be considered in case of arterial bleeding in a hemodynamic stable patient without other indication for OM (GoR 2 A).Severe head and spinal cord injuries should be considered as relative indications for OM, given the inability to reliably evaluate the clinical status (GoR 2A).The most recent published trials demonstrate a high success rate for NOM in 50 % of stab wounds (SW) in the anterior abdomen and in about 85 % in the posterior abdomen [6, 28]. The same concept has also been applied to gunshot wounds (GSWs) [29, 30]. However, a distinction should be made between low and high-energy penetrating trauma in deciding either for OM or NOM. In case of low energy, both SW and GSW, NOM can be safely applied. High energy GSW and other ballistic injuries are less amenable to NOM because of the high-energy transfer, and in 90 % of cases an OM is required [6, 31, 32]. Of note, a 25 % non-therapeutic laparotomy rate is reported in abdominal GSWs [31]. This confirms that in selective cases NOM could be pursued either in GSWs.Clinical trials report a high success rate of NOM in penetrating liver injuries (69 to 100 %) [29, 30, 32, 33, 34, 35, 36, 37]. Absolute requirements for NOM are: hemodynamic stability, absence of peritonitis, and an evaluable abdomen [6]. Evisceration and impalement are other indications for OM [30, 32, 34]. Current guidelines suggest that hemodynamically stable patients presenting with evisceration and/or impalement and/or diffuse peritonitis should be considered candidates to be directly taken to the OR without CT-scan [30]. These findings are particularly important in cases of gunshot injuries. Other suggested predictive criteria of NOM failure in abdominal GSWs according to Navsaria et al. are: associated head and spinal cord injuries (that preclude regular clinical examination) and significant reduction in hemoglobin requiring more than 2–4 units of blood transfusion in 24 h [6, 29].In SWs the role of CT scan has been questioned [28, 34]. Local wound exploration (LWE) is considered accurate in determining the depth of penetration; sometimes in little wounds it would be necessary to enlarge a little the incision [6, 30]. However, wound exploration near the inferior costal margin should be avoided if not strictly necessary because of the high risk to damage the intercostal vessels. Emergency laparotomy has been reported to be necessary even in some cases with negative CT-scan [34]. CT-scan may be necessary in obese patients and when the wound tract is long, tangential and difficult to determine the trajectory [6, 34].In NOM of GSWs the CT-scan can help in determining the trajectory. However not all authors consider it mandatory [29, 31]. Velmahos et al. reported a CT-scan specificity of 96 % and a sensitivity of 90.5 % for GSWs requiring laparotomy [38]. The gold standard to decide for OM or NOM remains the serial clinical examination [6, 31].NOM is contraindicated in case of CT-scan detection of free intra- or retro-peritoneal air, free intra-peritoneal fluid in the absence of solid organ injury, localized bowel wall thickening, bullet tract close to hollow viscus with surrounding hematoma [33] and in high energy penetrating trauma. In NOM strict clinical and hemoglobin evaluation should be done (every 4–6 h for at least 48 h); once stabilized the patient could be transferred to the ward [28, 29, 34].There is considerable variation in local CT-scan imaging practices, and no uniform standard exists. Variations are dependent on imaging hardware, radiation exposure, contrast dose, and image sequences, among other factors. For example, image acquisition may occur in a triphasic fashion (non-contrast, arterial, and portal venous phases), or as a single phase following a split bolus contrast injection, providing a mixed arterial and portal venous phase. These variables have not been standardized across centers, or in the literature, and require expert radiologist consideration and manipulation for optimal diagnostic yield, and are dependent on the study indication.Even in penetrating liver trauma, the angioembolization is considered as an “extension” of resuscitation in those patients presenting with ongoing resuscitative needs. However angioembolization can be applied safely only in selected centers [13, 20, 21]. If required it can be safely repeated.The main reluctance of surgeons to employ NOM in penetrating trauma is related to the fear of missing other abdominal lesions, especially hollow viscus perforation [6, 33]. Published data clearly showed that in patients without peritonitis on admission, no increase in mortality rates with missed hollow viscus perforation has been reported [39]. On the other hand, non-therapeutic laparotomy has been demonstrated to increase the complication rate [39]. Nevertheless OM in penetrating liver injuries has a higher liver-related complication rate (50–52 %) than in blunt ones [6, 33].Concomitant severe head injuriesThe otimal management of concomitant severe head and liver injuries is debated. In patients with severe head injuries hypotension may be deleterious, and OM could be suggested as safer [24, 36]. Recently, a large cohort of 1106 non-operatively managed low-energy gunshot liver injuries, has been published by Navsaria et al. [36]. The presence of concomitant liver and severe head injuries has been considered one of the main exclusion criteria to NOM. Authors stated that: “Hemodynamically stable patients with unreliable clinical examinations (head and/or high spinal cord injury) must also undergo an urgent exploratory laparotomy”. Another paper analyzing 63 patients by Navsaria et al. suggested as predictive criteria for NOM failure in abdominal low-energy GSWs is the association with head and spinal cord injuries precluding meaningful clinical examination [29].Follow-up after successful NOMClear and definitive direction for post-injury follow-up and normal activity resumption in those patients who experienced NOM haven’t been published yet. General recommendations are to resume usual activity after 3–4 months in patients with an uncomplicated hospital course. This derives from the observation that the majority of liver lesions heal in almost 4 months [10, 24]. If the CT-scan follow-up (in grade III-V lesions) has shown significant healing normal activity can be resumed even after 1 month [24].Patients should to be counseled not to remain alone for long periods and to return to the hospital immediately if they experience increasing abdominal pain, lightheadedness, nausea or vomiting [6, 10].Recommendations for operative management (OM) in liver trauma (blunt and penetrating)Patients should undergo OM in liver trauma (blunt and penetrating) in case of hemodynamic instability, concomitant internal organs injury requiring surgery, evisceration, impalement (GoR 2 A).Primary surgical intention should be to control the hemorrhage, to control bile leak and to institute an intensive resuscitation as soon as possible (GoR 2 B).Major hepatic resections should be avoided at first, and considered subsequently (delayed fashion) only in case of large devitalized liver portions and in centers with the necessary expertise (GoR 3 B).Angioembolisation is a useful tool in case of persistent arterial bleeding (GoR 2 A).As exsanguination represents the leading cause of death in liver injuries OM decision mainly depends on hemodynamic status and associated injuries [6].In those cases where no major bleeding are present at the laparotomy, the bleeding may be controlled by compression alone or with electrocautery, bipolar devices, argon beam coagulation, topical hemostatic agents, or omental packing [6, 8, 24, 40, 41].In presence of major haemorrhage more aggressive procedures can be necessary. These include first of all hepatic manual compression and hepatic packing, ligation of vessels in the wound, hepatic debridement, balloon tamponade, shunting procedures, or hepatic vascular isolation. It is important to provide concomitant intraoperative intensive resuscitation aiming to reverse the lethal triad [6, 8, 41].Temporary abdominal closure can be safely considered in all those patients when the risk of developing abdominal compartment syndrome is high and when a second look after patient’s hemodynamic stabilization is needed [8, 40, 41].Anatomic hepatic resection can be considered as a surgical option [2, 42, 43]. In unstable patients and during damage control surgery a non-anatomic resection is safer and easier [6, 8, 24, 44]. For staged liver resection, either anatomic either non-anatomic ones can be safely made with stapling device in experienced hands [44].If despite the fundamental initial maneuvers (hepatic packing, Pringle maneuver) the bleeding persists and evident lesion to a hepatic artery is found, an attempt to control it should be made. If repair is not possible a selective hepatic artery ligation can be considered as a viable option. In case of right or common hepatic artery ligation, cholecystectomy should be performed to avoid gallbladder necrosis [44, 45]. Post-operative angio-embolization is a viable option, when possible, allowing hemorrhage control while reducing the complications [6, 8, 24, 46]. After artery ligation, in fact, the risk of hepatic necrosis, biloma and abscesses increases [6].Portal vein injuries should be repaired primarily. The portal vein ligation should be avoided because liver necrosis or massive bowel edema may occur. Liver Packing and a second look or liver resection are preferable to portal ligation [6, 44].In those cases where Pringle maneuver or arterial control fails, and the bleeding persists from behind the liver, a retro-hepatic caval or hepatic vein injury could be present [6, 46]. Three therapeutic options exist: 1) tamponade with hepatic packing, 2) direct repair (with or without vascular isolation), and 3) lobar resection [7]. Liver packing is the most successful method of managing severe venous injuries [6, 24, 47, 48, 49]. Direct venous repair is problematic in non-experienced hands, with a high mortality rate [6, 24].When hepatic vascular exclusion is necessary, different types of shunting procedures have been described, most of them anecdotally. The veno-veno bypass (femoral vein to axillary or jugular vein by pass) or the use of fenestrated stent grafts are the most frequent type of shunt used by surgeons familiar with their use [8, 24, 44, 50]. The atrio-caval shunt bypasses the retro-hepatic cava blood through the right atrium using a chest tube put into the inferior cava vein. Mortality rates in such a complicated situations are high [8]. Liver exclusion is generally poorly tolerated in the unstable patient with major blood loss [6].In the emergency, in cases of liver avulsion or total crush injury, when a total hepatic resection must be done, hepatic transplantation has been described [44].The exact role of post-operative angio-embolization is still not well defined [51, 52, 53, 54, 55]. Two principal indications have been proposed: 1) after primary operative hemostasis in stable or stabilized patients, with an evidence at contrast enhanced CT-scan of active bleeding, and 2) as adjunctive hemostatic control in patients with uncontrolled suspected arterial bleeding despite emergency laparotomy [6, 56].ConclusionsThe management of trauma poses in definitive the attention in treating also the physiology and decision can be more effective when both anatomy of injury and its physiological effects are combined.AbbreviationsAAST: American Association for Surgery for TraumaATLS: Advanced Trauma Life SupportBLT: Blunt liver traumaDCS: Damage Control SurgeryERCP: Endoscopic retrograde cholangio-pancreatographyGSW: Gunshot woundNOM: Non-Operative ManagementOM: Operative ManagementOR: Operating RoomSW: Stab woundsWSES: World Society of Emergency SurgeryMoore EE, Cogbill TH, Jurkovich GJ, Shackford SR, Malangoni MA, Champion HR. 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Yes it could.Contrast media (sometimes called contrast agents or dye) are chemical substances used in medical X-ray, magnetic resonance imaging (MRI), computed tomography (CT), angiography, and occasionally ultrasound imaging.Contrast media enhance and improve the quality of images (or pictures) so that the radiologist (a specialist doctor trained to interpret the images) can more accurately report on how your body is working and whether there is any disease or abnormality present.Two commonly used contrast media are iodine-containing contrast medium and gadolinium contrast medium. These are used for CT scanning or angiography and MRI, respectively.The radiologist performing the procedure is responsible for deciding if contrast medium is needed and which contrast medium will provide the best images, depending on which part of the body is being scanned and the reason for the scan. This decision will be based on the information provided to the radiologist by your doctor or specialist on the referral form, such as your medical history and what your doctor or specialist thinks may be wrong with you.X-ray or radiography is the imaging of body structures using X-ray beams that are absorbed by different parts of the body in different ways to create an image or picture and this includes CT scans (see Computed Tomography (CT) and Plain radiography/X-rays.) This makes different structures in the body look lighter or darker on the images, depending on what these structures are made of, i.e. soft tissue shows as dark grey and bone as light grey. This difference in how different parts of the body absorb and transmit the X-ray beam is called contrast.MRI and ultrasound do not use radiation but also produce images of the body using a magnetic field, radiowaves, and sound energy, respectively. (see Magnetic Resonance Imaging)and ultrasound scans use high frequency soundwaves (see Ultrasound).The use of artificial contrast media enhances the contrast between different parts of the body. Contrast media is used to help distinguish between parts of the body that have a similar composition to provide a clearer image of how the body is working, or if there is any disease present.With clearer images, the radiologist can provide your doctor with a more accurate diagnosis of your symptom or condition, to assist in deciding what treatment will be most appropriate.Contrast media are not needed for every type of imaging test in order to obtain very high quality images. The radiologist will determine if the use of contrast will be helpful in your particular situation.