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Nonoperative Management of Grade IV Liver Injury for Elderly Patient

Nonoperative Management of Grade IV Liver Injury for Elderly Patient 10.2478/chilat-2014-0109 ACTA CHIRURGICA LATVIENSIS • 2014 (14/1) CASE REPORT Nonoperative Management of Grade IV Liver Injury for Elderly Patient Solvita Stabina*, *** Guntars Pupelis*,*** Reinis Laguns**, Aleksejs Kaminskis* *Riga East Clinical University hospital Gailezers, General and Emergency Surgery Departament, Latvia **Riga East Clinical University hospital Gailezers, Departament of Radiology, Latvia *** Riga Stradins University, Latvia SUMMARY According to current conventional practice 80% to 90% of hepatic injuries can be safely managed without operation. (2) Previously conservative management of the hepatic injuries were recommended for hemodynamically stable patients who did not require blood transfusion and number of trauma centres strongly recommended conservative strategy in alert patient who are able to cooperate with physical examination. However recent experience shows that the key factor in determining whether non-operative management (NOM) can be safely used is hemodynamic stability (HD) of the patient.(5) Key words: liver injury, hepatic trauma, operative management, non-operative management, blunt abdominal trauma, polytrauma AIM OF THE DEMONSTRATION DISCUSSION Is to report the successful outcome in elderly patient Approximately 1% to 8% of patients who sustain with high grade liver injury who was managed according blunt abdominal trauma have a liver injury. (4) Rapid to non-operative treatment protocol. deceleration in motor vehicle accidents produces shearing forces that cause different degrees of CASE REPORT parenchymal tears. The hepatic lobes may be torn from 71- year old female was delivered to the Emergency each other, or the tears may involve the supporting department (ED) four hours after accident with ligaments, hepatic veins, and inferior vena cava. The complaints about the chest and abdominal pain. most frequent site of hepatic injury is the posterior Patient suffered in an auto-pedestrian accident and segment of the right lobe of the liver due to its size after accident felt dizziness and weakness however and proximity to the ribs and spine. Although less was able to go home and to call- an ambulance. At the common, left lobe injuries are more often associated time of admission she was haemodynamically stable with retroperitoneal injuries (duodenum and pancreas) maintaining blood pressure 130/80 mmHg and heart rate and transverse colon injuries. (1)(5) 76 beats per minute. Chest X-ray revealed fracture of NOM (6) is indicatedin all haemodynamically stabile the IX rib. On focussed assessment with sonography for patients when signs of peritonitis are absent on abdominal trauma(FAST)- liver contusion with hemoperitoneum examination and surgeon is able to follow serial physical examinations, delineate hepatic injury and CT scan were found. confirms absence of other intra-peritoneal injuries. CT showed liver laceration involving hepatic segments Another important consideration is minimal transfusion 7,8 (grade IV) and diffuse fluid collection in the peritoneal requirements not exceeding 2 units of packed red blood cells (PRBCs). Complications of NOM such as biloma, cavitywithout evidence of active extravasation.Elevated aspartate amino transferase (AST 465.41 U/L) and biliary fistula, intra-abdominal abscess, hepatic abscess, haemobilia can be treated with percutaneous drainage, alanine aminotransferase (ALT 617.05 U/L) were the only abnormal blood tests. Haemoglobin was 12.30 g/ but missed hollow viscus injury, ongoing bleeding, liver necrosis and abdominal compartment syndrome often dL and patient was haemodynamically stable during the primary assessment period. Patient was delivered requires surgical treatment. to the Intensive care unit with the CT proved grade IV liver injury for NOM.Abdominal ultrasound and blood tests were repeated every 6 hours at the first day and once a day next 48 hours. This strategy was successful and patient was transferred to the surgical department. Overall hospital stay was 10 days. Patient was dischargedin a good conditionfor outpatient treatment. 41 ACTA CHIRURGICA LATVIENSIS • 2014 (14/1) REFERENCES 1. Boone DC, Federle M, Billiar TR, et al Evolution of management of major hepatic trauma: Identification of patterns of injury // J Trauma, 1995; 39: 344 – 350 CrossRef 2. Carillo EH, Platz A, Richardson JD, et al: Nonoperative management of blunt hepatic trauma // Br J Surg, 1997; 85: 4651 CrossRef 3. Jeffrey RB, Olcott EW: Imaging of blunt hepatic 15.04.2014 Abdominal CT (at the admission) trauma // Radiol Clin North Am, 1991; 29: 1299 – 4. Matthes G, Stengel D, Seifert J, et al Blunt liver in polytrauma: Results from a cohort study with the regular use of whole – body helical computed tomography // World J Surg, 2003; 27: 1124 – 1130 CrossRef 5. Oschner MG: Factors of failure of nonoperative management of blunt liver and splenic injuries // World J Surg, 2001; 25: 1393 22.04.2014 Abdominal CT (7 days after trauma) 6. Alexander L. Eastman, David H. Rosenbaum and Erwin R. Thal // Parkland Trauma Handbook, The Conflict of interest: None Third Edition 27, 210 – 22 Adress: Solvita Stabina Talavas gatve 13 – 8, Riga, Latvia E-mail: solvita.stabina@inbox.lv http://www.deepdyve.com/assets/images/DeepDyve-Logo-lg.png Acta Chirurgica Latviensis de Gruyter

Nonoperative Management of Grade IV Liver Injury for Elderly Patient

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Abstract

10.2478/chilat-2014-0109 ACTA CHIRURGICA LATVIENSIS • 2014 (14/1) CASE REPORT Nonoperative Management of Grade IV Liver Injury for Elderly Patient Solvita Stabina*, *** Guntars Pupelis*,*** Reinis Laguns**, Aleksejs Kaminskis* *Riga East Clinical University hospital Gailezers, General and Emergency Surgery Departament, Latvia **Riga East Clinical University hospital Gailezers, Departament of Radiology, Latvia *** Riga Stradins University, Latvia SUMMARY According to current conventional practice 80% to 90% of hepatic injuries can be safely managed without operation. (2) Previously conservative management of the hepatic injuries were recommended for hemodynamically stable patients who did not require blood transfusion and number of trauma centres strongly recommended conservative strategy in alert patient who are able to cooperate with physical examination. However recent experience shows that the key factor in determining whether non-operative management (NOM) can be safely used is hemodynamic stability (HD) of the patient.(5) Key words: liver injury, hepatic trauma, operative management, non-operative management, blunt abdominal trauma, polytrauma AIM OF THE DEMONSTRATION DISCUSSION Is to report the successful outcome in elderly patient Approximately 1% to 8% of patients who sustain with high grade liver injury who was managed according blunt abdominal trauma have a liver injury. (4) Rapid to non-operative treatment protocol. deceleration in motor vehicle accidents produces shearing forces that cause different degrees of CASE REPORT parenchymal tears. The hepatic lobes may be torn from 71- year old female was delivered to the Emergency each other, or the tears may involve the supporting department (ED) four hours after accident with ligaments, hepatic veins, and inferior vena cava. The complaints about the chest and abdominal pain. most frequent site of hepatic injury is the posterior Patient suffered in an auto-pedestrian accident and segment of the right lobe of the liver due to its size after accident felt dizziness and weakness however and proximity to the ribs and spine. Although less was able to go home and to call- an ambulance. At the common, left lobe injuries are more often associated time of admission she was haemodynamically stable with retroperitoneal injuries (duodenum and pancreas) maintaining blood pressure 130/80 mmHg and heart rate and transverse colon injuries. (1)(5) 76 beats per minute. Chest X-ray revealed fracture of NOM (6) is indicatedin all haemodynamically stabile the IX rib. On focussed assessment with sonography for patients when signs of peritonitis are absent on abdominal trauma(FAST)- liver contusion with hemoperitoneum examination and surgeon is able to follow serial physical examinations, delineate hepatic injury and CT scan were found. confirms absence of other intra-peritoneal injuries. CT showed liver laceration involving hepatic segments Another important consideration is minimal transfusion 7,8 (grade IV) and diffuse fluid collection in the peritoneal requirements not exceeding 2 units of packed red blood cells (PRBCs). Complications of NOM such as biloma, cavitywithout evidence of active extravasation.Elevated aspartate amino transferase (AST 465.41 U/L) and biliary fistula, intra-abdominal abscess, hepatic abscess, haemobilia can be treated with percutaneous drainage, alanine aminotransferase (ALT 617.05 U/L) were the only abnormal blood tests. Haemoglobin was 12.30 g/ but missed hollow viscus injury, ongoing bleeding, liver necrosis and abdominal compartment syndrome often dL and patient was haemodynamically stable during the primary assessment period. Patient was delivered requires surgical treatment. to the Intensive care unit with the CT proved grade IV liver injury for NOM.Abdominal ultrasound and blood tests were repeated every 6 hours at the first day and once a day next 48 hours. This strategy was successful and patient was transferred to the surgical department. Overall hospital stay was 10 days. Patient was dischargedin a good conditionfor outpatient treatment. 41 ACTA CHIRURGICA LATVIENSIS • 2014 (14/1) REFERENCES 1. Boone DC, Federle M, Billiar TR, et al Evolution of management of major hepatic trauma: Identification of patterns of injury // J Trauma, 1995; 39: 344 – 350 CrossRef 2. Carillo EH, Platz A, Richardson JD, et al: Nonoperative management of blunt hepatic trauma // Br J Surg, 1997; 85: 4651 CrossRef 3. Jeffrey RB, Olcott EW: Imaging of blunt hepatic 15.04.2014 Abdominal CT (at the admission) trauma // Radiol Clin North Am, 1991; 29: 1299 – 4. Matthes G, Stengel D, Seifert J, et al Blunt liver in polytrauma: Results from a cohort study with the regular use of whole – body helical computed tomography // World J Surg, 2003; 27: 1124 – 1130 CrossRef 5. Oschner MG: Factors of failure of nonoperative management of blunt liver and splenic injuries // World J Surg, 2001; 25: 1393 22.04.2014 Abdominal CT (7 days after trauma) 6. Alexander L. Eastman, David H. Rosenbaum and Erwin R. Thal // Parkland Trauma Handbook, The Conflict of interest: None Third Edition 27, 210 – 22 Adress: Solvita Stabina Talavas gatve 13 – 8, Riga, Latvia E-mail: solvita.stabina@inbox.lv

Journal

Acta Chirurgica Latviensisde Gruyter

Published: Nov 24, 2014

Keywords: Medicine; Clinical Medicine; Surgery; Surgery, other

References