Liver Injury Grading Calculator

How does this Liver injury grading calculator work?

This is a health tool that allows clinicians and emergency room physicians to quickly assess hepatic injury due to blunt trauma. Based on the 6 item liver laceration grading scale established by the AAST American Association for the Surgery of Trauma, patients are evaluated, diagnosed and sent either for further investigation after imagistic like CT has been obtained or directly towards observatory surgery.

This Liver injury grading calculator provides the full descriptions for each of the six levels of trauma severity as explained here:

Grade I

■ Haematoma: subcapsular, <10% surface area;

■ Laceration: capsular tear, <1 cm depth.

Grade II

■ Haematoma: subcapsular, 10-50% surface area;

■ Haematoma: intraparenchymal <10 cm diameter;

■ Laceration: capsular tear, 1-3 cm depth, <10 cm length.

Grade III

■ Haematoma: subcapsular, >50% surface area, or ruptured with active bleeding;

■ Haematoma: intraparenchymal >10 cm diameter;

■ Laceration: capsular tear, >3 cm depth.

Grade IV

■ Haematoma: ruptured intraparenchymal with active bleeding;

■ Laceration: parenchymal disruption involving 25-75% hepatic lobes or involves 1-3 Couinaud segments (within one lobe).

Grade V

■ Vascular: juxtahepatic venous injuries (inferior vena cava, major hepatic vein);

■ Laceration: parenchymal disruption involving >75% of hepatic lobe or involves >3 Couinaud segments (within one lobe).

Grade VI

■ Vascular: hepatic avulsion;

■ Laceration present or not.

As observed, the degrees vary, starting with I, the least severe to VI, the most severe. The rule of thumb states that any injury classified at a stage higher than II will most likely require surgical correction and in some cases, preparation for blood transfusion. Most presentations are given the first three grades, according to the National Trauma Data Bank (NTDB). Surgery usually aims at controlling the hemorrhage as the most common cause of death in hepatic trauma in surgery is exsanguinations.

Liver trauma, either blunt or penetrating consists of 5% of all trauma presentations with abdominal injury. It is prone to stab wounds and shooting wounds due to the abdominal position and the large surface covered. Fractures of the lower ribs on the right side are frequently accompanied by underlying liver damage. Presentation includes pain and tenderness in the right abdominal quadrants with pain irradiating to the right shoulder. When bleeding is present, patients will present symptoms of shock, with rapid heart rate, pale or bluish skin and cold teguments.

Hepatic injury ranges from haematomas, which are described as collection of blood, of various sizes, shapes and locations, to large ruptures, lacerations of liver tissue of different depths. Due to the intense vascularisation of this organ, most traumas are accompanied by bleeding in various degrees, bleeding that occurs in the abdominal cavity.

Diagnosis is mainly based on ultrasound and computer tomography investigations and can observe from shape damage, lacerations to bleeding sources. Hemodynamically unstable patients are usually referred for a FAST scan (focused assessment with sonography for trauma).

In terms of laboratory tests, there are no specific findings to indicate liver trauma although the usual signs of distress due to trauma may be present, such as elevated white blood cell count. Red blood cells don’t exhibit a relevant change while anemia following posttraumatic hemorrhage might have a delay in installation.

References

1) Yoon W, Jeong YY, Kim JK, Seo JJ, Lim HS, Shin SS, Kim JC, Jeong SW, Park JG, Kang HK. (2005) CT in blunt liver trauma. Radiographics; 25(1):87-104.

2) Bouras AF, Truant S, Pruvot FR. (2010) Management of blunt hepatic trauma. J Visc Surg; 147(6):e351-8

3) Stracieri LD, Scarpelini S. (2006) Hepatic injury. Acta Cir Bras; 21 Suppl 1:85-8.

4) Ahmed N, Vernick J. (2011) Management of liver trauma in adults. J Emerg Trauma Shock; 4(1): 114–119.