Grade IV blunt hepatic injury treated conservatively and successfully in a non-trauma centre: a case report

Sebastian Berg, Jean-Charles de Schoutheete, Davide Di Mauro, Matteo Gregori, Edoardo Ricciardi, Antonio Manzelli


Management of blunt hepatic injury changed over the past three decades as a non-operative treatment is nowadays advocated by most in haemodynamically stable patients. We present the case of a young female patient with a high-grade blunt liver injury successfully treated in a non-trauma centre. She developed several complications secondary to the injury like a delayed bleeding, two different bilomas and a reactive pleural effusion requiring surgical expertise, interventional radiology, upper gastro-intestinal endoscopy and intensive care facilities. In the literature, the mortality and the morbidity rates for grade IV liver injuries respectively reach 16% and 39%. Because of potential delayed symptoms or signs and high complication rate, we think it should be appropriate to manage such a complex patient in a centre where at least above-mentioned specialities are available. Otherwise, a referral to a trauma centre should be a better option.


Trauma, Blunt hepatic injury, Nonoperative management, Interventional radiology, Endoscopy

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Parks RW, Chrysos E, Diamond T. Management of liver trauma. Br J Surg. 1999;86:1121-35.

Morrison JJ, Bramley KE, Rizzo AG. Liver trauma--operative management. J R Army Med Corps. 2011;157(2):136-44.

Boese CK, Hackl M, Müller LP, Ruchholtz S, Frink M, Lechler P. Nonoperative management of blunt hepatic trauma: a systematic review. J Trauma Acute Care Surg. 2015;79(4):654-60.

Fodor M, Primavesi F, Morell-Hofert D, Haselbacher M, Braunwarth E, Cardini B et al. Non-operative management of blunt hepatic and splenic injuries-practical aspects and value of radiological scoring systems. Eur Surg. 2018;50(6):285-98.

Parks NA, Davis JW, Forman D, Lemaster D. Observation for nonoperative management of blunt liver injuries: how long is long enough? J Trauma. 2011;70(3):626-9.

Hommes M, Navsaria PH, Schipper IB, Krige JEJ, Kahn D, Nicol AJ. Management of blunt liver trauma in 134 severely injured patients. Injury. 2015;46(5):837-42.

Kozar RA, Moore FA, Moore EE, West M, Cocanour CS, Davis J et al. Western Trauma Association critical decisions in trauma: nonoperative management of adult blunt hepatic trauma. J Trauma. 2009;67(6):1144-8.

Fabian TC, Bee TK. Liver and Biliary Tract. In: Feliciano D, Mattox K, Moore E, editors. Trauma 6th ed. McGraw-Hill Medical. 2008;851-70.

Bala M. Complications of high-grade liver injuries: management and outcome with focus on bile leaks. Scandinavian J Trauma, Resuscitation and Emergency Med. 2012;20:20.

Moore EE, Shackford SR, Pachter HL, McAninch JW, Browner BD, Champion HR et al. Organ injury scaling: spleen, liver, and kidney. J Trauma. 1989;29:1664-6.

Moore EE, Cogbill TH, Jurkovich GJ, Shackford SR, Malangoni MA, Champion HR. Organ injury scaling: spleen and liver. J Trauma. 1995;38:323-4.

Stassen NA, Bhullar I, Cheng JD, Crandall ML, Friese RS, Guillamondegui OD et al. Eastern Association for the Surgery of Trauma. Nonoperative management of blunt hepatic injury: an Eastern Association for the Surgery of Trauma practice management guideline. J Trauma Acute Care Surg. 2012;73(5-4):S288-93.

Velmahos GC, Toutouzas KG, Radin R, Chan L, Demetriades D. Nonoperative treatment of blunt injury to solid abdominal organs: a prospective study. Arch Surg. 2003;138(8):844-51.

Yanar H, Ertekin C, Taviloglu K, Kabay B, Bakkaloglu H, Guloglu R. Nonoperative treatment of multiple intra-abdominal solid organ injury after blunts abdominal trauma. J Trauma. 2008;64(4):943-8.

Fang JF, Wong YC, Lin BC, Hsu YP, Chen MF. The CT risk factors for the need of operative treatment in initially hemodynamically stable patients after blunt hepatic trauma. J Trauma. 2006;61:3.

Fang JF, Chen RJ, Wong YC, Lin BC, Hsu YB, Kao JL et al. Pooling of contrast material on computed tomography mandates aggressive management of blunt hepatic injury. Am J Surg. 1998;176(4):315-9.

Piper GL, Peitzman AB. Current management of hepatic trauma. Surg Clin North Am. 2010;90(4):775-85.

Velamhaos GC, Konstantinos T, Radan R, Chan L, Rhee P, Tillou A et al. High success with nonoperativemanagement of blunt hepatic trauma. Arch Surg. 2003;138:475-81.

Coimbra R, Hoyt DB, Engelhart S, Fortlage D. Nonoperative management reduces the overall mortality of grades 3 and 4 blunt liver injuries. Int Surg 2006;91(5):251-7.

Shrestha B, Holcomb JB, Camp EA, Del Junco DJ, Cotton BA, Albarado A et al. Damage-control resuscitation increases successful nonoperative management rates and survival after severe blunt liver injury. J Trauma Acute Care Surg. 2015;78:336-41.

Zago TM, Pereira BMT, Calderan TRA, Godinho M, Nascimento B, Fraga GP. Nonoperative management for patients with grade IV blunt hepatic trauma. World J Emergency Surg. 2012;7(1):S8.

Kozar RA, Moore JB, Niles SE. Complications of non-operative management of high-grade blunt hepatic injuries. J Trauma. 2005;59:1066-071.

Duane TM, Como JJ, Bochicchio GV, Scalea TM. Re-evaluating the management and outcomes of severe blunt liver injury. J Trauma. 2004;57(3):494-500.

Schnüriger B, Inderbitzin D, Schafer M, Kickuth R, Exadaktylos A, Candinas D. Concomitant injuries are an important determinant of outcome of blunt hepatic trauma. Br J Surg. 2009;96:104-10.

Carrillo EH, Spain DA, Wohltmann CD, Schmieg RE, Boaz PW, Miller FB et al. Interventional techniques are useful adjuncts in nonoperative management of hepatic injuries. J Trauma. 1999;46:619-22.

Kozar RA, Moore FA, Cothren CC. Risk factors for hepatic morbidity following nonoperative management. Arch Surg. 2006;141:451-8.

Singh V, Narasimhan KL, Verma GR, Singh G. Endoscopic management of traumatic hepatobiliary injuries. J Gastroenterol Hepatol. 2007;22:1205-9.

Lubezky N, Konikoff FM, Rosin D, Carmon E, Kluger Y, Ben-Haim M. Endoscopic sphincterotomy and temporary internal stenting for bile leaks following complex hepatic trauma. Br J Surg. 2006;93:78-81.

Carrillo EH, Spain DA, Wohltmann CD, Schmieg RE, Boaz PW, Miller FB et al. Interventional techniques are useful adjuncts in nonoperative management of hepatic injuries. J Trauma. 1999;46(4):619-22.

De Backer A, Fierens H, De Schepper A, Pelckmans P, Jorens PG, Vaneerdeweg W. Diagnosis and nonsurgical management of bile leak complicated by biloma after blunt liver injury: report of two cases. Eur Radiol. 1998;8(9):1619-22.

D’Amours SK, Simons RK, Scudamore CH, Nagy AG, Brown DR. Major intrahepatic bile duct injuries detected after laparotomy: selective nonoperative management. J Trauma. 2001;50(3):480-84.

Nathan M, Gates J, Ferzoco SJ. Hepatic duct confluence injury in blunt abdominal trauma: case report and synopsis on management. Surg Laparosc Endosc Percutan Tech. 2003;13(5):350-2.