Non-operative approaches to major blunt hepatic (Grade IV): a case report

Abstract

Background

Recent advancements in the management of pediatric liver trauma have highlighted the effectiveness of non-operative management as the preferred therapeutic approach. This report presents the case of an 8-year-old patient who sustained significant liver trauma from a substantial fall, successfully managed through non-operative management.

Case presentation

An 8-year-old Iranian child presented with a Grade IV liver laceration and contusion, pneumothorax, and rib fractures after a 1.5 m fall. Initial stable vitals were confirmed. Diagnostic evaluations included serial focused assessment with sonography for trauma scans and computed tomography imaging of the thorax, abdomen, and pelvis. Treatment involved intensive care unit monitoring, intravenous fluid therapy, and a chest tube insertion. The patient’s condition improved significantly after 6 days in the intensive care unit, demonstrating the efficacy of non-operative management. The patient was successfully discharged following conservative management. Written informed consent was obtained from the patient’s legal guardian for publication of this case report and any accompanying images.

Conclusions

This case highlights the effectiveness of non-operative management in managing high-grade liver injuries. Over the past 2 decades, non-operative management has become increasingly prevalent, particularly in urban healthcare settings, due to its ability to manage hepatic trauma without surgical risks. Advanced imaging and multidisciplinary approaches are critical to its success.

Introduction

Liver trauma is one of the most commonly encountered abdominal injuries in patients with severe trauma [1]. Most of these patients present with minor to moderate injuries classified as World Society of Emergency Surgery (WSES) I, II, or III or American Association of Surgery of Trauma Organ Injury Scale (AAST-OIS) I, II, or III, and these are typically managed successfully using non-operative management (NOM) [2]. In pediatric patients, NOM is generally regarded as the optimal treatment approach. Although anatomical characterization of liver lesions is essential, it is not solely sufficient for determining the most appropriate treatment strategy. The decision to pursue surgical intervention or NOM is primarily influenced by the patient’s hemodynamic stability, the extent of concomitant injuries, and the anatomical grade of the liver injury [2]. In patients identified as transient responders with moderate to severe hepatic injuries, NOM should only be considered in highly specialized settings. These settings must have immediate access to a multidisciplinary team of experienced healthcare professionals and the necessary facilities for close monitoring and prompt intervention [3]. NOM requires hemodynamic stability and the absence of concomitant injuries that necessitate surgical intervention [4]. Implementing NOM for moderate to severe blunt or penetrating trauma necessitates comprehensive diagnostic capabilities to identify all associated injuries and ensure intensive patient management. We describe a clinical case of major (Grade IV) liver injury in a pediatric male successfully treated with NOM.

Case report

An 8-year-old Iranian child presented to the emergency department at Bam Pastour Medical Center in Kerman Province with an abdominal injury sustained from a fall from a height of 1.5 m. Upon arrival, the patient was conscious and oriented, with a Glasgow Coma Scale (GCS) score of 15. Vital signs included a blood pressure of 100/80 mmHg and a heart rate of 135 beats per minute, indicating tachycardia. Physical examination revealed abrasions on the right side of the abdomen and thorax. Pulmonary auscultation detected right-sided rales and diminished breath sounds. The patient reported right-sided abdominal pain without rebound tenderness, and peripheral pulses were palpable. Initially, blood samples were collected for preliminary laboratory investigations. The patient was administered oxygen therapy and received intensive fluid resuscitation with 1300 cc of crystalloid intravenous fluid, accompanied by continuous monitoring. A focused assessment with sonography for trauma (FAST) was conducted in the emergency department. Subsequent diagnostic imaging included additional radiographs of the chest and pelvis. The patient underwent a non-contrast computed tomography (NCCT) scan of the thorax and a contrast-enhanced computed tomography (CECT) scan of the abdomen and pelvis. The imaging findings from both ultrasonography and computed tomography (CT) confirmed the presence of linear hypoechoic regions and increased echogenicity in the parenchyma of the right hepatic lobe, consistent with a Grade IV liver laceration and contusion (Fig. 1). Additionally, mild free fluid was observed in the abdominal and pelvic cavities. As a result, the patient was promptly transferred to the intensive care unit (ICU) for further intensive management and monitoring. The patient’s hemodynamic status stabilized following the administration of intravenous fluids (dextrose saline) and the transfusion of 120 cc of blood. This intervention effectively restored circulatory volume and improved tissue perfusion, resulting in a stable hemodynamic state. Additionally, radiographic evidence revealed a lung injury accompanied by mild pneumothorax (Fig. 2). Furthermore, a fracture line was observed in the posterior aspects of the VIII, IX, and X ribs on the right side. Laboratory results during hospitalization indicated that hemoglobin levels, serum alanine transaminase (ALT), aspartate transaminase (AST), and serum amylase were within normal ranges. However, coagulation profile assessments revealed abnormal parameters, with prothrombin time (PT) extended by 3 seconds. Due to the diagnosis of mild pneumothorax, the patient was closely monitored in the ICU. On the following day, the patient was transferred to the operating room, where a right-sided chest tube (thoracostomy) was inserted under general anesthesia (Fig. 3). The chest tube facilitated the re-expansion of the affected lung and the evacuation of air from the pleural space. Continuous monitoring ensured that the patient’s vital signs remained within normal ranges, reducing the risk of further complications. Additionally, the patient was administered cefotaxime at a dosage of 1 g every 8 hours to reduce the risk of infection. Furthermore, the patient received 8 cc of 15% w/v potassium chloride to address potential electrolyte imbalances and support overall metabolic function. Concurrently, paracetamol (acetaminophen) was administered at a dosage of 100 mg every 12 hours to treat mild to moderate pain and fever. Given the patient’s presentation of mild abdominal pain, the absence of peritoneal irritation signs, and stable vital signs, despite the presence of a Grade IV blunt hepatic laceration, the patient was deemed an appropriate candidate for conservative (NOM) management. This decision was based on the patient’s hemodynamic stability and the absence of indications necessitating immediate surgical intervention. After 6 days in the ICU, which included daily clinical evaluations and a single abdominal ultrasound, no signs of ongoing bleeding were detected, and the patient’s overall condition improved significantly. Consequently, the NOM strategy was deemed successful, and the patient was transferred to a general surgery ward for continued observation and care. The patient was subsequently discharged after 2 days. Following discharge, the patient was enrolled in a follow-up program to ensure ongoing recovery and monitor for any potential complications. Initially, the patient adhered to complete bed rest. At the 1-week follow-up, a complete blood count (CBC) and abdominal and pelvic ultrasound were performed, demonstrating satisfactory progress. At the 2-week follow-up, continued improvement was confirmed with another CBC and ultrasound. By the 3-week mark, an additional outpatient visit showed normal results for both CBC and ultrasound, indicating successful resolution of the liver laceration and associated injuries. The patient’s recovery was meticulously monitored, ensuring no complications arose during this period. This comprehensive follow-up plan facilitated a thorough and effective recovery. Written informed consent was obtained from the patient’s legal guardian for publication of this case report and any accompanying images.

Fig. 1

The computed tomography scan of the abdomen demonstrates a Grade IV liver laceration in the patient. The location of the laceration is highlighted with a red circle and marked by a red arrow

Fig. 2

The imaging reveals a mild pneumothorax in the patient’s right lung. The location of the pneumothorax is encircled in red and indicated with a red arrow

Fig. 3

The chest tube was inserted on the patient’s right side

Discussion

In recent decades, there have been significant advancements in the management of pediatric liver trauma. During the early twentieth century, surgical interventions for these injuries were prevalent but often had limited success. However, the 1960s marked the advent and gradual adoption of NOM for such cases [5]. In instances of blunt abdominal trauma, the liver is the most frequently injured organ, followed by the spleen [6]. In younger children, playground accidents are frequent causes of liver injuries. Currently, over 90% of solid organ injuries in pediatric patients are managed using NOM. However, missing an associated injury can have severe consequences. An abnormal physical exam remains one of the most reliable indicators of abdominal injury in children. Signs of hypovolemic shock, including poor perfusion, tachycardia, and mental status changes in abdominal trauma, are ominous findings that suggest significant bleeding and require urgent evaluation and management [5, 7]. Besides, the wide diffusion of high-resolution CT scan and interventional radiology procedures, together with several important clinical observations, transformed the diagnosis and management of blunt abdominal trauma [8]. Liver trauma management is influenced by the injury severity. Prior research indicates that patients with minor liver injuries typically respond well to NOM, which involves conservative treatment methods. Conversely, more severe liver injuries may require emergency laparotomy, a surgical intervention that can be crucial for saving the patient life [9]. Ensuring hemodynamic stability, which includes a thorough and immediate assessment of the patient airway, breathing, and circulation, is critical in deciding the course of treatment. When vital parameters are stable, it allows for a NOM approach, emphasizing close clinical monitoring supplemented by radiological and laboratory evaluations [10, 11]. We applied a similar approach to our patient with a high-grade liver injury (Grade IV). Despite the severity of the injury, the patient’s pulse and blood pressure remained within normal ranges. Serial hemoglobin levels showed stability, and FAST scans indicated no immediate need for surgical intervention. Despite the patient having a Grade IV liver injury, pneumothorax, and fractures of three ribs, their condition remained stable. Specifically, studies demonstrate a 70% safety profile for NOM in patients with Grade IV and V liver injuries, thereby challenging the conventional reliance on surgical exploration [3, 12]. NOM of blunt liver trauma has emerged as a highly reliable therapeutic approach, with numerous studies documenting its significant efficacy and benefits [13]. Over the past 2 decades, there has been a marked increase in the adoption of non-surgical protocols for managing blunt hepatic traumas, particularly in urban healthcare settings. Research indicates that for the past 20 years, the avoidance of surgical intervention has been a cornerstone strategy, enabling physicians to manage hepatic trauma cases more effectively [3]. The use of screening and imaging techniques to assess trauma severity has been emphasized as critically important. Although FAST plays a crucial role as a rapid diagnostic tool, CECT has been recognized as a superior evaluation and diagnostic method for liver trauma. It is particularly effective in identifying parenchymal lacerations, bruising, internal bleeding, liver abscesses, peritonitis, and other complications (14). Our patient underwent multiple FAST scans at several-hour intervals. These were followed by CECT of the thorax, abdomen, and pelvis. These diagnostic evaluations allowed us to determine and implement the most effective treatment plan. Furthermore, patient demonstrated a favorable response to intravenous fluid administration, indicating the effective maintenance of hemodynamic stability through intravenous fluid therapy.

Conclusion

The maintenance of hemodynamic stability is paramount in the management of patients with blunt hepatic trauma. NOM has now been established as the gold-standard therapeutic approach. It involves meticulous clinical observation, targeted medical therapies, judicious blood transfusions, and high-quality diagnostic evaluations. This management necessitates ICU observation to ensure patient stability and promptly address any complications. The establishment of trauma centers that employ a multidisciplinary physician approach to assess the severity of injuries, regardless of the patient’s age, is essential. An optimal and timely decision-making process is crucial for improving the overall prognosis in managing blunt hepatic trauma cases within emergency healthcare settings.