Diagnosis and treatment of rupture liver due to blunt abdominal trauma for 5 years in Military Hospital 103

Nội dung text: Diagnosis and treatment of rupture liver due to blunt abdominal trauma for 5 years in Military Hospital 103

1. Journal OF MILITARY PHARMACO - MEDICINE N06 - 2021 DIAGNOSIS AND TREATMENT OF RUPTURE LIVER DUE TO BLUNT ABDOMINAL TRAUMA FOR 5 YEARS IN MILITARY HOSPITAL 103 Nguyen Van Tiep1, Lai Ba Thanh1 SUMMARY Objectives: To study the clinical and subclinical characteristics and treatment outcomes of patients with ruptured liver due to blunt abdominal trauma (BAT) at Military Hospital 103. Subjects and methods: A descriptive retrospective study in 85 patients diagnosed with ruptured liver due to BAT from 2015 - 2020. Results: Patients had an average age of 32.5 ± 15.2. The percentage of male patients was 80. A traffic accident was the most common reason for BAT (64.7%). Clinical signs on admission: 9.4% of cases went into shock, 17.6% had polytrauma, 72.9% had an abdominal hemorrhage, 68.2% had hemodynamic stability, and 24.7% had hemodynamic instability. 7.1% of patients had bradycardia and hypotension, 35.3% had associated injuries, and 1.2% had peritonitis. Death within the first 24 hours or death after emergency surgery occurred in 3.5% of cases. Abdominal ultrasound revealed that 60.0 % of cases had free fluid in the peritoneal cavity. CT demonstrated rupture liver of levels I, II, III, IV, V were 9.4%, 35.3%, 32.9, 16.5, and 5.9%, respectively. 84.7% of cases were treated conservatively: 35.5% underwent abdominal drainage under ultrasound guidance, 48.2% were treated via pharmacological methods, and 15.3% via open surgery. Operations were more often performed for patients with hemodynamic instability (p < 0.05). The average length of hospital stay was 9.0 ± 4.6 days. Conclusion: Diagnosis of the ruptured liver due to BAT depended on intra-abdominal symptoms, abdominal ultrasound, and CT. Patients with hemodynamic stability were often treated conservatively, and operations were often given for patients with hemodynamic instability. * Keywords: Abdominal trauma; Ruptured liver due to BAT. INTRODUCTION in number and extent of the damage. Liver trauma is a very common solid The most common cause of liver trauma organ injury in closed abdominal trauma is mainly traffic accidents. According to (second after ruptured splenic), accounting some authors in the West, about 70% of for 15 - 20% [1, 2]. Recently, the rate of liver trauma cases are caused by traffic liver trauma has increased markedly both accidents [3]. According to statistics, 1Military Hospital 103, Vietnam Military Medical University Corresponding author: Nguyen Van Tiep (chitamduc@gmail.com) Date received: 8/4/2021 Date accepted: 26/4/2021 188
2. Journal OF MILITARY PHARMACO - MEDICINE N06 - 2021 CT scan abdomen allows determining abdominal CT imaging, and lesions how much damage the liver parenchyma determined during surgery. with images hematoma in parenchymal 2. Methods hematoma subcapsular, contusion, torn * Study design: A retrospective study. tissue, blood in the abdominal cavity with Data including clinical features, causes injury combination [4]. Thereby making of injury, presence of traumatic shock, 31% of multi-injury cases had closed intra-abdominal hemorrhage, peritonitis, abdominal injury, of which 16% were and other coordinated injuries were reported to have liver trauma [2]. The collected. Treatment of liver trauma due diagnosis of liver injury is based on to blunt abdominal injury by non-operative clinical manifestations of the syndrome, or operative treatments was also bleeding in the peritoneal cavity, based on determined. The data was gathered and clinical ultrasound and computerized processed on Excel software with tomography. fundamental changes in statistical algorithms. views and attitudes treatment of liver injury in 30 years. Regarding treatment, RESULTS previous surgical indications for liver injury are very spacious. Today, advances 1 Patients characteristics and causes in resuscitation anesthesia, surgical of injury: techniques, and intravascular interventions Average age: 32.5 ± 15.2, the lowest is have reduced mortality from liver injury. 7 years old, the highest is 75 years old, The trend of non-surgical conservative most of them are in the working-age treatment for patients with liver injury group of 20 - 40 years old, accounting for grades I, II, III with hemodynamic stability 53% of the sample population. is increasing and achieving good results Male: 68 patients (80%); female: [5, 6, 7]. We carried out this research: To 17 patients (20%), male/female ratio: 4:1 summarize the experience related to the - Causes of injury: diagnosis and treatment of liver injury at + Traffic accidents: 55 patients, Military Hospital 103 in the 5 years from accounting for 64.7%. 2015 to 2020. + Household accidents: 17 patients, SUBJECTS AND METHODS accounting for 20.0%. 1. Subjects + Working accidents: 9 patients, accounting for 10.6%. 85 patients hospitalised from January 2015 to January 2020 at Military Hospital + Assault: 4 patients, accounting for 103, who was diagnosed with liver trauma 4.7%. due to blunt abdominal injury based on Traffic accidents are the most common clinical features, ultrasound imaging, cause of blunt liver injury. 189
3. Journal OF MILITARY PHARMACO - MEDICINE N06 - 2021 2. Clinical features in blunt abdominal injury Table 1 Variable Number of patients (n) Ratio (%) The conditions of patients when hospitalised - Shock 8 9.4 - Polytrauma 15 17.6 - Coordinated damage 30 35.3 - Abdominal hemorrhage 62 72.9 - Acute peritonitis 1 1.2 - Death 3 3.5 The period of time from accidents to hospitalisation - (≤ 6h) 40 47.1 - (6 - 12h) 18 21.1 - (12 - 24h) 18 21.1 - (> 24h) 9 10.6 Ultrasonography and ultrasound-guided abdominocentesis - Fluid 51 60 - Evidence of liver injury 64 75.3 Computer imaging⃰ - Grade I 8 9.4 - Grade II 30 35.3 - Grade III 28 32.9 - Grade IV 14 16.5 - Grade V 5 5.9 - Grade VI 0 0.0 * Grading liver rupture on CT base on Liver Injury AAST Grading System Patients’ hemodynamic conditions when hospitalised (heart rate and blood pressure): - Hemodynamically stable (HR ≤100 bpm, systolic BP ≥ 100mmHg): 58/85 patients (68.2%). - Hemodynamically unstable (100mmHg < HR ≤140 bpm and 80 mmHg < systolic BP ≤ 100mmHg): 21/85 patients (24.7%). - Rapid but weak pulse, low blood pressure (HR >140 bpm and systolic BP < 80mmHg): 6/85 patients (7.1%). 190
4. Journal OF MILITARY PHARMACO - MEDICINE N06 - 2021 Table 2: The relationship between CT imaging and hemodynamics of patients on admission. Grade on CT I II III IV V VI Total Hemodynamic Stable hemodynamics 8 28 21 1 0 0 58 Unstable hemodynamics 0 2 7 12 0 0 21 Rapid but weak pulse, 0 0 1 5 0 6 low blood pressure 8 30 28 14 5 0 85 Total (9.4%) (35.3%) (32.9%) (16.5%) (5.9%) (0.0%) (100.0%) Table 3: Treatments. Treatments Number of patients (n) Ratio (%) Non-operative Observation only 41 48.2 management Ultrasound-guided peritoneal lavage 31 36.5 Operative management Suture hemostasis 13 15.3 Total 85 100.0 Table 4: The relationship between treatment and patients’ hemodynamics on admission. Hemodynamic Stable Unstable Rapid but weak Total Treatment hemodynamic hemodynamic pulse, low BP Non-operative management 58 14 0 72 Operative management 0 7 6 13 Total 58 (68.2%) 21(24.7%) 6 (7.1%) 85 p < 0,05 Table 5: The relationship between treatment and CT imaging. Grade on CT I II III IV V VI Total Treatment Non-operative management 8 28 27 9 0 0 72 Operative management 0 2 1 5 5 0 13 8 30 28 14 5 0 85 Total (9.4%) (35.3%) (32.9%) (16.5%) (5.9%) (0%) (100%) Average time of hospitalisation: 9.0 ± 4.6 days. 191
5. Journal OF MILITARY PHARMACO - MEDICINE N06 - 2021 DISCUSSION According to Doklestić, patients with high-grade liver trauma who present with * Patient’s characteristics: hemorrhagic shock and associated - Average age: 32.5 ± 15.2 years old, severe injury should be managed the lowest is 7 years old, whereas the operatively. Mortality from liver trauma is highest is 75 years old, most of them high for patients with higher AAST grade are in the group of 20 - 40 years old, of injury, associated brain injury, and account for 53%, which is the group of massive transfusion score [8]. working age. - Coordinated damage: 30 patients Male/Female: 4/1. (35.5%) have coordinated damage, with The most common cause of liver injury injuries to 5 regions of the body: brain, is traffic accidents which account for 64.7%. chest, abdomen, limbs, and face. According to Doklestić Road, traffic accident - Multiple trauma: 15 patients (17.6%) was the leading cause of trauma, seen in have multiple trauma, with severe damage 90.0% [8]. in 2 different regions of the body, affecting * Clinical features: crucial functions of the body. - The period of time from accidents to - Abdominal hemorrhage: frequently admission: Most patients are admitted to seen in blunt liver injury. 72.9% of patients the hospital in less than 24h, accounting have abdominal hemorrhage syndrome. for 89.6%. - Acute peritonitis: there is 1 case with - Death: 3 patients died (3.5%). Two jejunal damage and liver injury. They patients died from multiple trauma and were given an early diagnosis by hypovolemic shock due to damage of ultrasound-guided abdominocentesis. multiple organs: abdominal hemorrhage, * Subclinical features: pleural effusion, pneumothorax, complicated - Ultrasonography is a valuable pelvic trauma. The third patient died after method of diagnosis and prognosis in an emergency operation due to right pleural treating liver rupture due to BAT. 75.3% of effusion, pelvic injury, right kidney rupture, liver lesions were detected on ultrasound, diaphragmatic rupture. The patient was in and 60% were detected on ultrasound- for liver sutures, nephrectomy, left pleural guided abdominocentesis (table 1). cavity drainage, repair of diaphragmatic - CT was also a valuable tool for tear, and died after 2 hours. The rate of diagnosis and evaluation of liver rupture death was even lower in a study by due to BAT. In the study of detection of Siddiqui (2020), which was 10% [9]. liver injury by grade I, II, III, IV, and V, the - Shock: 8 patients were in shock and detection rate was 9.4, 35.3, 32.9, 16.5 had a severe abdominal hemorrhage. 8/8 and 5.9%, respectively. The majority of patients had resultant multiple trauma patients with liver rupture of I, II, III have shock. The reason for shock in blunt stable hemodynamics, while patients with abdominal injury patients is mostly due to unstable hemodynamics had liver rupture loss of blood and multiple trauma. of grade IV and V (Table 2). 192
6. Journal OF MILITARY PHARMACO - MEDICINE N06 - 2021 * Treatment: Treated by surgical methods: 13 patients Surgery used to be the treatment of (15.3%) underwent surgery. The commonly choice in cases of blunt hepatic injury, but used surgical method here is the suture this approach gradually changed over the of the liver wound. Based on Table 4, last two decades as increasing non- the 13 patients received emergency operative management (NOM) of splenic surgery 7 patients with hemodynamic injury led to its use for hepatic injury. The instability, 6 patients have expressed improvement in critical care monitoring shock, rapid pulse small, difficult to detect and computed tomographic scanning, pulse, hypotension. In the case of patients as well as the more frequent use of with liver rupture admitted to the hospital interventional radiology techniques, has in hemodynamic instability after the helped to bring about this change to non- dialysis has been active and the fluid has operative management [10]. According to not progressed, the indication for surgery Hommes (2015), in stable hemodynamic should be made early in order to save the patients without an acute abdomen, non- patient's life. From Table 5, rupture liver operative management (NOM) of blunt damage for patients with surgical liver injuries has become the standard of treatment usually splenic rupture liver care with a reported success rate of rupture of the IV and V 10/13 patients. between 80 and 100% [2]. In a study by 3 patients with grade III liver rupture, Cirocchi, minor injuries (grade I or II) are and the second due to surgery after the most frequent liver injuries (80% to conservative treatment by means of 90% of all cases); severe injuries are peritoneal fluid drainage under ultrasound grade III-V lesions; grade VI lesions are guidance. After a few days, 1 patient with frequently incompatible with survival. In bile leakage expression while 2 other the medical literature, the majority of patients show signs of bleeding in the patients who have undergone NOM have abdomen near 1-week relapse after low-grade liver injuries. The safety of conservative treatment. According to NOM in high-grade liver lesions, AAST Table 4, conservative treatment was grade IV and V, remains a subject of applied to the majority of patients debate as a high incidence of liver and (84.7%). Liver rupture grade I, II, III is collateral extra-abdominal complications often conserved, the success rate is very is still described. [10] high. With the grade, IV rupture can also In this research, according to table 4, be treated conservatively when the hemodynamics was the most important patient has hemodynamic stability. In the factor affecting the decision to consider study, 9 patients with grade IV rupture the medical therapy: Non-operative were successfully conserved in treatment. management (NOM) or surgery. On Nowadays, conservative and minimally studying NOM for the patient with invasive treatments are the trend for liver unstable hemodynamics, surgery was rupture injury treatment. Another method indicated for a patient with unstable that we have not used for liver rupture is hemodynamic (p < 0.05). the hepatic vascular node. In addition, it is 193
7. Journal OF MILITARY PHARMACO - MEDICINE N06 - 2021 also possible to use laparoscopic surgery 2. Hommes, M., et al. Management of to diagnose and manage liver rupture blunt liver trauma in 134 severely injured grade II and III that have complications patients. Injury 2015; 46(5):837-842. such as biliary fistula or a combination of 3. Slotta, J.E., et al. Liver injury following hollow viscera but in the case of patients blunt abdominal trauma: A new mechanism- with hemodynamic stability. driven classification. Surg Today 2014; 44(2):241-246. The average hospital stays for liver 4. Yoon, W., et al. CT in blunt liver damage to be treated: 9.0 ± 4.6 days. trauma. Radiographics 2005; 25(1):87-104. CONCLUSION 5. Schembari, E., et al. Blunt liver trauma: Effectiveness and evolution of non-operative Ruptured liver caused by blunt abdominal management (NOM) in 145 consecutive trauma is a surgical emergency. The common cases. Updates Surg 2020; 72(4):1065-1071. cause is traffic accidents (67.7%). 6. Swift, C. and J.P. Garner, Non- Diagnosis of the ruptured liver is mainly operative management of liver trauma. J R based on signs and symptoms, including Army Med Corps 2012; 158(2):85-95. abdominal bleeding syndrome (72.9%), 7. Yanar, H., et al. Nonoperative treatment abdominal ultrasound detecting abdominal of multiple intra-abdominal solid organ injury fluid (60%), and liver lesions (75.3%). after blunt abdominal trauma. J Trauma 2008; CT scans demonstrating liver rupture 64(4):943-948. grades I, II, III, IV are 9.4, 35.3, 32.9, 8. Doklestić, K., et al. Severe blunt hepatic 16.5, and 5.9%, respectively. Treatment trauma in polytrauma patient - management and outcome. Srp Arh Celok Lek 2015; 143(7- of ruptured liver is mainly based on the 8):416-422. patient's hemodynamic. NOM is indicated 9. Siddiqui, N.A., et al. Non-operative for patients with stable hemodynamics, treatment of hepatic trauma: A changing and surgery is indicated for patients with paradigm. A Six year review of liver trauma unstable hemodynamics (p < 0.05). patient in a single institute. J Pak Med Assoc 2020; 70(Suppl 1)(2):S27-S32. REFERENCES 10. Cirocchi, R., et al. Non-operative 1. Leenen, L.P. Abdominal trauma: From management versus operative management operative to nonoperative management. Injury in high-grade blunt hepatic injury. Cochrane 2009; 40 (4):S62-S68. Database Syst Rev 2015; (8):Cd010989. 194