Guideline sources The following summarized guidelines for the evaluation and management of liver trauma are prepared by our editorial team based on guidelines from the World Society of Emergency Surgery (WSES 2020), the Society of Interventional Radiology (SIR 2020), the European Federation of Societies for Ultrasound (EFSU 2020), the World Society of Emergency Surgery (WSES/AAST 2019), and the Eastern Association for the Surgery of Trauma (EAST 2012). 1 2 3 4 5 Guidelines 1. Diagnostic investigations Ultrasound: obtain extended FAST for rapid detection of intra-abdominal free fluid. A Computed tomography: As per WSES 2020 guidelines, obtain CT with IV contrast as the gold standard in hemodynamically stable patients with trauma A , and in patients considered for nonoperative management of liver trauma. B As per EAST 2012 guidelines: https://web.pathway.md/diseases/recEUidHBoorIRBbs 1/5 6/29/23, 5:53 AM Liver trauma Pathway As per EAST 2012 guidelines: Obtain abdominal CT with IV contrast to identify and assess the severity of liver injury in hemodynamically stable patients with blunt abdominal trauma without peritonitis. B Obtain reevaluation with CT in patients with persistent systemic inflammatory response, increasing persistent abdominal pain, jaundice, or an otherwise unexplained drop in Hgb. B Magnetic resonance cholangiopancreatography: consider obtaining MRCP with hepatobiliary contrast for the diagnosis of suspected biliary injuries. B Hepatobiliary scintigraphy: do not obtain hepatobiliary scintigraphy for detection of biliary leak in patients with suspected gallbladder and biliary injuries in the trauma setting. D 2. Diagnostic procedures Endoscopic retrograde cholangiopancreatography: consider performing ERCP in hemodynamically stable or stabilized adult and pediatric patients with suspected extrahepatic biliary tree injury. B 3. Medical management Setting of care: consider admitting patients with isolated liver injury with moderate (WSES II/AAST III) or severe (WSES III/AAST IV-V) lesions to an ICU. C Non-operative management: As per SIR 2020 guidelines, initiate nonoperative management as the treatment of choice in hemodynamically stable patients with blunt hepatic injury. B As per WSES 2020 guidelines, initiate nonoperative management as the treatment of choice in all hemodynamically stable patients with minor (WSES I/AAST I-II), moderate (WSES II/AAST III), or severe (WSES III/AAST IV-V) liver injuries in the absence of other internal injuries requiring surgery. B Show 5 more As per EAST 2012 guidelines: Recognize that the severity of liver injury (as suggested by CT grade or degree of hemoperitoneum), neurologic status, age of > 55 years, and/or the presence of associated injuries are not absolute contraindications to a trial of nonoperative management in hemodynamically stable patients. B Consider initiating nonoperative management in patients with liver injury only in an environment that provides capabilities for monitoring, serial clinical evaluations, and an operating room available for urgent laparotomy. C Thromboprophylaxis: As per WSES 2020 guidelines, consider applying mechanical prophylaxis in all patients with liver injury with no absolute contraindication. B Show 2 more https://web.pathway.md/diseases/recEUidHBoorIRBbs 2/5 6/29/23, 5:53 AM Liver trauma Pathway As per EAST 2012 guidelines, consider administering pharmacologic prophylaxis for the prevention of VTE in patients with isolated blunt liver injuries without increasing the failure rate of nonoperative management. Insufficient evidence to recommend an optimal timing of safe initiation. C 4. Nonpharmacologic interventions Enteral feeding: initiate enteral feeding as soon as possible in the absence of contraindications in patients with liver injury. B Early mobilization: advise early mobilization in stable patients with liver injury. B 5. Therapeutic procedures Angiography with embolization: As per SIR 2020 guidelines, consider performing embolization in patients with blunt hepatic injury with ongoing bleeding, identification of an arterial source of bleeding on imaging, or suspicion of a persistent source of arterial bleeding despite operative intervention. C As per WSES 2020 guidelines, consider performing angigraphy with embolization as a first-line intervention in hemodynamically stable patients with liver injury with an arterial blush on CT. C Show 4 more As per EAST 2012 guidelines: Consider performing angiography with embolization as first-line intervention in patients transiently responding to resuscitation as an adjunct to potential operative intervention. C Consider performing angiography with embolization in hemodynamically stable patients with evidence of active extravasation (a contrast blush) on abdominal CT. C Resuscitative endovascular balloon occlusion of the aorta: consider performing REBOA as a bridge to other more definitive procedures for hemorrhage control in hemodynamically unstable patients with liver injury. C Other interventions for complications: As per WSES 2020 guidelines, consider performing percutaneous drainage in patients with intrahepatic abscesses and symptomatic or infected bilomas. B Show 2 more As per EAST 2012 guidelines, consider performing interventional procedures, including ERCP, angiography, laparoscopy, or percutaneous drainage, for the management of complications (bile leak, biloma, bile peritonitis, hepatic abscess, bilious ascites, and hemobilia) arising as a result of nonoperative management of blunt liver injury. C 6. Surgical interventions https://web.pathway.md/diseases/recEUidHBoorIRBbs 3/5 6/29/23, 5:53 AM Liver trauma Pathway Indications for surgery: As per WSES 2020 guidelines, perform surgery in hemodynamically unstable and non- responding patients (WSES IV) with liver injury. B Show 4 more As per EAST 2012 guidelines: Perform urgent laparotomy in hemodynamically unstable patients or in patients with diffuse peritonitis after blunt abdominal trauma. A Do not perform routine laparotomy in hemodynamically stable patients without peritonitis presenting with an isolated blunt liver injury. D 7. Specific circumstances Pediatric patients: obtain follow-up contrast-enhanced ultrasound for the assessment of complications and reducing ionizing radiation exposure in pediatric patients with traumatic liver injuries. B Clinical findings Symptoms Past events RUQ pain Blunt abdominal trauma Vital signs Abdominal exam Hypotension Abdominal distension Signs of shock Peritoneal findings RUQ tenderness Lab findings Seat belt sign Signs of internal hemorrhage serum ALT serum AST serum LDH serum base deficit serum gamma- glutamyltransferase serum lactate References 1. Nicole A Stassen, Indermeet Bhullar, Julius D Cheng et al. Nonoperative management of blunt hepatic injury: an Eastern Association for the Surgery of Trauma practice management guideline. J Trauma Acute Care Surg. 2012 Nov;73 5 Suppl 4 S288 93. Open https://web.pathway.md/diseases/recEUidHBoorIRBbs 4/5 6/29/23, 5:53 AM Liver trauma Pathway 2. Federico Coccolini, Raul Coimbra, Carlos Ordonez et al. Liver trauma: WSES 2020 guidelines. World J Emerg Surg. 2020 Mar 30;15 1 24. Open 3. Siddharth A Padia, Christopher R Ingraham, John M Moriarty et al. Society of Interventional Radiology Position Statement on Endovascular Intervention for Trauma. J Vasc Interv Radiol. 2020 Mar;31 3 363 369.e2. Open 4. Federico Coccolini, Leslie Kobayashi, Yoram Kluger et al. Duodeno-pancreatic and extrahepatic biliary tree trauma: WSES AAST guidelines. World J Emerg Surg. 2019 Dec 11;14 56. Open 5. Christoph F Dietrich, Christian P llson Nols e, Richard G Barr et al. Guidelines and Good Clinical Practice Recommendations for Contrast-Enhanced Ultrasound CEUS in the Liver-Update 2020 WFUMB in Cooperation with EFSUMB, AFSUMB, AIUM, and FLAUS. Ultrasound Med Biol. 2020 Oct;46 10 2579 2604. Open 6. Rosemary A Kozar, Marie Crandall, Kathirkamanthan Shanmuganathan et al. Organ injury scaling 2018 update: Spleen, liver, and kidney. J Trauma Acute Care Surg. 2018 Dec;85 6 1119 1122. 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