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ORIGINAL RESEARCH
Injury pattern, outcomes and management of liver trauma
Imran Ahmed, Shahkamal Hashmi, Farzeen Tanwir, Saadia Ahmed, Muhammad Nadeem

Introduction

Results
The present study consists of 61 patients with hepatic trauma.
Thirty patients (49.18%) out of sixty-one, were of liver trauma
alone and thirty-one patients (50.81%) of liver trauma with
associated injuries. Three patients were female and 58 were
male patients with a male to female ratio of 19.3:1.

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Issue 2

This is a prospective clinical study that was carried out in Jinnah Postgraduate Medical Centre, Karachi, Pakistan from 1st
January 2010 to 31st December 2011. It included 61 cases of
liver trauma, due to both penetrating and non-penetrating injuries, on the basis of clinical features and fulfilling inclusion
criteria, admitted though accident and emergency department.

2014 Volume 6

Materials and Method

A database was developed on SPSS for window version 17.0

on the basis of questionnaire. For the quantitative variables
mean standard deviation (S.D) was calculated and for their
comparison t-test was applied. For the qualitative data chisquare test was used where applicable, other wise yates corrected chi square was mentioned. Inclusion criteria included
age group equals or more than 13 years of age with diagnosis
of liver trauma, all the patients with penetrating and non-penetrating injury to liver, all the patients with blunt and sharp
injury to liver. Exclusion criteria included all patients less than
13 years of age, patients with pre-existing liver disease i.e. cirrhosis, tumors, hepatitis etc and patients who have previously
undergone hepatic surgery.

Trauma is one of the leading causes of mortality worldwide for

all age groups.1 The liver is the largest solid abdominal organ
and involves majority of metabolic functions of the body.2 Despite the relative protection by overlying ribs, it is susceptible
to compressive forces by means of blunt trauma that can injure the soft parenchyma.3,4 Motor vehicle accidents are one
of the most frequent causes of traumatic hepatic injury4 There
could be a greater propensity for blunt liver injuries to occur
in countries where the driver occupies the right side of the vehicle than those where the drivers sits on the left side. Major
liver trauma is frequently associated with coagulopathy.5 The
developments in diagnosis, resuscitation and advent of new
surgical technique have opened a new chapter in the management of liver injuries. In the past decades the use of CT
SCAN has changed the diagnostic and therapeutic approach
to such injuries completely,6 decreasing the options for surgical intervention. The purpose of this study was to document
different modes of presentation and treatment of liver trauma
of the patients and to document morbidity and mortality of
cases included in the study in a tertiary care setting in Karachi
from 1st January 2000 to 31st December 2001.

This study included adult patients both male and female. Clinical data regarding age, sex, mode and type of injuries were
taken and recorded. After initial resuscitation, clinical evaluation and thorough examination, those patients who were hemodynamically stable, were admitted to the ward and managed conservatively. Ultrasound or CT SCAN was done in all
cases managed conservatively. Patients, who were hemodynamically unstable, managed surgically according to grading
of liver injury. Resuscitation, treatment options and outcome
were recorded on a performa, which was specifically generated for the purpose.

I N T E R N AT I O N A L J O U R N A L O F D E N TA L C L I N I C S

Abstract
Aims and Objectives: To determine the major injury patterns, outcomes and management options of liver trauma in a
tertiary care setup in Karachi, Pakistan. Materials and Methods: A prospective clinical study that was carried out consisted
of 61 patients with liver trauma, 58 males and 3 female, with the mean age 31.46 years. Data regarding age, sex, mode
and type of injuries were taken and analyzed. Inclusion criteria included age group equals or more than 13 years of age
with diagnosis of liver trauma, patients penetrating and non-penetrating traumatic injury to liver, patients with blunt
and sharp injury to liver. Exclusion criteria included all the patients less than 13 years of age, patients with pre-existing
liver disease i.e. cirrhosis, tumors, hepatitis etc, Patients who have previously undergone hepatic surgery. This study was
conducted during the time period of 1st January 2010 till 31st December 2011. The data was analyzed using SPSS 17.
Results: The incidence of liver trauma due to non-penetrating injuries was 47(77%) while due to penetrating injuries 14
(23.0%), with a value of p= 0.001. In all cases of blunt injuries, 67.2% patients were presented due to road traffic accidents,
and 9.8% patients were due to assaults. In all cases of liver trauma, 08 patients (13%) sustained Grade I liver injury, 27
patients (44.3%) had Grade II liver injury, 20 patients (32.8%) of Grade III liver injuries, 04 (6.6%) patients of Grade IV and
02(3.3%) of Grade V liver injury. 17(27.9%) patients were hemodynamically stable, and managed Medically with strict
vital monitoring, input/output charting and repeated examinations. 44(72%) patients were hemodynamically unstable
despite aggressive resuscitation and were managed surgically. Conclusion: Non-penetrating liver injuries are most common (77.0%) in our population especially due to road traffic accidents (67.0%). Surgical management has a provital role
in saving life where the patient is hemodynamically unstable.
Keywords: Blunt Injury; Hemodynamically Stable; Liver Trauma; Sharp Injury

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Ahmed et al

Injury pattern, outcomes and management of liver trauma

Gender

Female

Age
Mean + SD

Range

Median

28.33+ 4.04

24.0-32.0

29.0

Male

58

31.62+ 5.28

18.0-42.0

32.0

Total

61

31.46+ 5.25

Frequency

Non- Penetrating

47

77%

P=0.001

Penetrating

14

23%

Total

61

100%

Chi-Square=47.66

Table 2. Type of Liver Injury

Grade

Frequency

Mortality

13.1%

P=0.001

II

27

43.3%

III

20

32.8%

IV

6.6%

3 (4.9%)

3.3%

2 (3.3%)

VI

Total

61

100%

5 (8.1%)

Chi-Square=47.66

Table 3. Grade of Liver Injury

Management

Frequency

Conservative

17

27.9%

Surgical

44

72.1%

Total

61

Table 4. Type of Management

N

Frequency

95% C.I.

Suturing

18

40.1%

16.1-69.5

Hepatotomy

13

29.5%

08.9-58.9

Mesh Wrapping

6.88%

0.20-31.5

Perihepatic Packing

Omental Plug

18.2%

3.3-46.5

Resection Debridement

4.5%

0.0-27.9

Segmental Lobectomy

Total

44

72.13%

47.3-89.9

Table 5. Surgical Options for Liver Injury

Complications

Frequency

Chest Infectiion

27

44.26%

Jaundice

07

11.5%

Wound Infection

06

09.8%

Ext. Biliary Fistula

09

14.8%

Total

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Table 6. Complications of Liver Injury

Out of a total of 61 patients 08 patients (13%) were of Grade

I liver injury, 27 patients (44.3%) of Grade II liver, 20 patients
(32.8%) of Grade III liver injuries. There were 20 (6.6%) patients
of Grade IV and 02(3.3%) of Grade V liver injury. We have not
found Grade VI liver injury in our setup. (Table 3). The mortality
and morbidity rate in liver trauma varied significantly depending upon the mechanism of injury and impact of injury. Both
the patients (3.3%) with liver injury of Grade V and 3 out of 4
patients (4.9%) with Grade IV were expired. The 95% C.I was
0.7-27.8.Both patients of Grade V liver injury expired during
surgery because of complex hepatic injuries. Others two were
expired on 3rd and 5th postoperative day due to multi organ
failure.
In this study out of a total of 61 patients 17(27.9%) patients
were haemodynamically stable, and managed Medically with
strict vital monitoring, input/output charting and repeated
examination to asses the conditions. 44(72%) patients were
haemodynamically unstable despite aggressive resuscitation
and were managed surgically. (Table 4)
The choice of different surgical options for securing homeostasis in liver trauma depends upon type and mode of injury,
grade of liver injury, and clinical assessment. Most of liver injuries required simple suture ligation.
Simple suture ligation was done in 18 patients(40%) with a
95% C.I of 16.1-69.5, hepatotomy done in 13 patients(29.8%)
with a 95% C.I of 8.9-58.9, absorbable mesh was placed in 03
patients(6.8%) with a 95% C.I of 0.2-31.5, omental patch done
in 08 patients(18.2%) with a 95% C.I of 3.3-46.5 and resectional
debridement was done in 02 patents(4.5%) with a 95% C.I of
0.0-89.9.
There were 45.9% patients in shock at the time of presentation with increase respiratory rate, pulse rate and decrease
blood pressure. The Res. Rate of the patients in this study had
a mean +S.D of 29.42+ 4.67, ranging 20.0-34.0 with a median
of 31.0. Pulse Rate with a mean + S.D of 119.91-10.1, ranging
98.0-135.0 with a median of 122. Systolic blood pressure in this
study was of mean+ S.D. of 87.87, ranging 75.0-110.0 with a
median of 85.0. Shock was defined as systolic blood pressure

Complications developed in patients treated Medically and

Surgically. Out of 61 patients, 27 (44.26%) developed chest
complication i.e. atelectasis, dry cough, productive cough
and pneumonia. 07 patients (11.5%) developed temporary
jaundice due to liver injury. Wound infection developed in 06
patients (9.8%) and external biliary fistula developed in 09 patients (14.75%). (Table 6)
Discussion
Trauma is the leading cause of deaths and disability in young
people both in developed and developing countries.1 Injuries
with their associated direct and indirect costs results in considerable financial burden on the family and relatives.7,8 Trauma has been the major cause of emergency admission in our
setup.
The present study consisted of 61 patients with hepatic trauma. Thirty patients (49.18%) out of 61, were of liver trauma
alone and 31 patients (50.81%) were of liver trauma with
associated injuries. Fifty eight patients were male and three
were female patients with a male to female ratio of 19.3:1. this
shows high male to female ratio compared to other studies
because females are mostly non-Ambulant. A study done in
Qatar by Faramawy et al, demonstrated male to female ratio of
11.6:1. 9 The reason for this male preponderance is that males
are more exposed and projected to trauma than females due
to outdoor activities. Another study done in Saudi Arabia by
Barrimah et al showed almost twice the number of male to
female having road traffic accidents ( major cause of traumatic
liver injury) in that year.10
The average age of the patients was 32 for male and 29 for female in our study. In a study done in Italy during 1999 to 2010
by Li Petri et al, the average age was 33 years which is almost
equal to the males average age.11
In this study, the incidence of liver trauma due to non-penetrating injuries was 77% of the cases including 67.2% due to
road traffic accidents and 9.8% due to assaults, and the incidence of penetrating liver injuries was 23% including 19.7%
due to firearm injuries and 3.3% due to stab injuries. The reason for high incidence of non-penetrating liver injuries is the
reckless driving, unnecessary overtaking, and negligence of
traffic law enforcement. Fonsica Neto et al, in a Portuguese
study determined that the closed abdominal trauma was the
most prevalent amongst all traumas (67.9%), in the penetrating injuries 24.8% were due to firearm.12
The grades of liver injuries in this study are comparable to
other studies. Amongst 90.2% of the all patients which were
operated, 13% were of Grade I, 44.3% of Grade II, 32.8% of
Grade III liver injuries. There were 6.6% patients of Grade IV
and 3.3% of Grade V. We have not found Grade VI liver injury
in our setup. In a previous study, there were 68.1% of the pt
with hepatic trauma were found to fall in Grade I-III, while only

31.9 were in grade IV- VI. 13Another study done by Zargar and
Laal, showed that the frequency of grade I hepatic injury was
27.4%, grade II was 32.1%, grade III was 22.6%, grade IV 8.3%,
grade V 4.8% and grade VI 4.8%. Hence the overall incidence
for grade I-III was more than 82% of all cases.13
In our study 27.9% patients were found to be hemodynamically stable, and managed medically with strict vital monitoring,
input/output charting and repeated examination to assess the
conditions. 72% patients were haemodynamically unstable
despite aggressive resuscitation and therefore were managed
surgically. The choice of different surgical options for securing
homeostasis in liver trauma depended on type and mode of
injury, grade of liver injury and surgeon own discretion.
Most of liver injuries required simple suture ligation. Simple
suture ligation was done in 18 patients (40%), hepatotomy
done in 13 patients (29.8%), absorbable mesh was placed in
three patients (6.8%), omental patch placed in eight patients
(18.2%) and resectional debridement was done in two patents
(4.5%). According to a study done in Iran, the most frequent
option in operated patients with liver trauma was suturing
(72.2%), packing was done in 11.1% of the patients, resection
and debridement was the choice in 13%, while only 3.7% of
the patients underwent Cholecystectomy. 13
There were 45.9% patients in circulatory shock at the time of
first presentation, with the systolic blood pressure measuring
80 mmHg or less, these patients were aggressively resuscitated with crystalloids, colloids and blood products, and were
prepared for a lapratomy.
Diagnostic peritoneal lavage or four-quadrant tap was not
performed in any patient. Anatomical resection and major resection of complex hepatic injury were not done due to high
mortality associated with it.
The mortality and morbidity rate in liver trauma vary significantly depending upon the mechanism of injury and severity
of injury. Both the patients with liver injury of Grade V and 3
out of 4 patients with Grade IV expired. Both patients of Grade
V liver injury expired during surgery because of complex injuries. Others two expired on 3rd and 5th postoperative day
due to multiorgan failure. Zargar and Laal reported that the
mortality rate among the hepatic trauma patients was highest
with grade IV-VI which was 80% of the overall mortality rate.
Grade II-III accounted for only 20% of the overall mortalities
while there was no mortality in grade I hepatic injury.13 Another study by Bala et al, analyzed the data for only grade III, IV
and V hepatic injuries, for which 69% of the adjusted mortality
was for grade V hepatic injuries, followed by 29% for grade IV
while only 21% with grade III, this showed an extremely high
mortality rate for the higher groups notably for grade V.14 In
another study, grade V mortality was found out to be 63.6%,
grade IV 26.3%, grade III 5.3%, grade II with 14.7% and no mortality with grade I.15
Complications developed in patients were treated both conservatively and surgically. Out of 61 patients 27 (44.26%)

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2014 Volume 6 Issue 2

Surgical Options

In this study, the incidence of liver trauma due to non-penetrating injuries was 47(77%) while due to penetrating injuries
14 (23.0%), with a value of p= 0.001 and Chi-Square=47.66.
Out of 47 cases of blunt injuries, 41 patients (67.2%) were
presented due to road traffic accidents with a 95% C.I of 1.1931.11, 06 patients (9.8%) were due to assaults with a 95% C.I
of 5.35-43.53. Out of 14(23%) patients of penetrating injuries,
12 patients (19.7%) involve to firearm injuries with a 95% C.I
of 5.35-43.58, and 02 patients (3.3%) due to stab injuries with
a 95% C.I of 0.02-20.89. the statistical value were p=0.001 and
Chi-Square= 94.21.(Table 2)

of 80 mmHg or less. These patients were aggressively resuscitated with crystalloids, colloids and blood products, and shifted to emergency operation theatre for surgery. (Table 5)

I N T E R N AT I O N A L J O U R N A L O F D E N TA L C L I N I C S

Type of Injury

The mean age of the patients for female was 28.33+ 4.04 years
(mean+ S.D) ranging from 24-32 years with median age of 29,
and for male was 31.62+ 5.28 years (mean +S.D) ranging from
18- 42 years with a median age of 32.(Table 1)

I N T E R N AT I O N A L J O U R N A L O F D E N TA L C L I N I C S

2014 Volume 6 Issue 2

Table 1. Demographic Distribution

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Ahmed et al

developed chest complication i.e. atelectactesis, dry cough,

productive cough and pneumonia. Seven patients (11.5%) developed jaundice, wound infection developed in six patients
(9.8%) and external biliary fistula developed in nine patients
(14.75%).
Conclusion

I N T E R N AT I O N A L J O U R N A L O F D E N TA L C L I N I C S

2014 Volume 6 Issue 2

In conclusion, non-penetrating liver injuries are most common (77.0%) in this study population especially due to road
traffic accidents (67.0%). Hemorrhage is the leading cause of
death in liver trauma. In hemodynamically stable patients,
non-operative management is safe and rewarding. Surgical
intervention was found to be live saving in hemodynamically
unstable patients.
Authors Affiliation

1. Imran Ahmed, MBBS, FCPS, Assistant Professor, Department of

Surgery, Ziauddin University, Karachi, Pakistan, 2. Shahkamal Hashmi, MBBS, MSC, Assistant Professor, Department of Surgery, Ziauddin
University, Karachi, Pakistan, 3. Farzeen Tanwir, BDS, PhD, Associate
Professor, Department of Postgraduate Studies and Research, Ziauddin University, Karachi, Pakistan, 4. Saadia Ahmed, MBBS, Assistant
Professor, Department of Surgery, Ziauddin University, Karachi, Pakistan, 5. Muhammad Nadeem BDS, MDS, Department of Periodontology, Head of Community Dentistry and Periodontology, Liaquat College of Medicine and Dentistry, Dental Block, Darul Sehat Hospital,
Karachi, Pakistan.

7. Corso P, Finkelstein E, Miller T, Fiebelkorn I, Zaloshnja E. Incidence

and lifetime costs of injuries in the United States. Injury Prevention. 2006;12(4):212-8.
8. Chang DC, Anderson JE, Kobayashi L, Coimbra R, Bickler SW. Projected lifetime risks and hospital care expenditure for traumatic
injury. Journal of surgical research. 2012;176(2):567-70.
9. El-Faramawy A, El-Menyar A, Zarour A, Maull K, Riebe J, Kumar
K, et al. Presentation and outcome of traumatic spinal fractures.
Journal of emergencies, trauma, and shock. 2012;5(4):316-20.
10. Barrimah I, Midhet F, Sharaf F. Epidemiology of road traffic injuries
in qassim region, saudi arabia: consistency of police and health
data. International journal of health sciences. 2012;6(1):31-41.
11. Petri SL, Gruttadauria S, Pagano D, Echeverri GJ, Francesco Fd,
Cintorino D, et al. Surgical management of complex liver trauma:
a single liver transplant center experience. The American surgeon. 2012;78(1):20-5.
12. Fonseca-Neto OCLd, Ehrhardt R, Miranda ALd. Morbimortality in
patients with hepatic trauma. ABCD Arquivos Brasileiros de Cirurgia Digestiva (So Paulo). 2013;26(2):129-32.
13. Zargar M, Laal M. Liver trauma: operative and Nonoperative
management. International Journals of Collaborative Research
on Internal Medicine & Public Health. 2010;2(4):96-107.

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How cite this article

3. Chien L-C, Lo S-S, Yeh S-Y. Incidence of liver trauma and relative
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Ahmed I, Hashmi S, Tanwir F, Ahmed S, Nadeem M. Injury pattern,

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Address for Correspondence

Dr. Muhammad Nadeem BDS, MDS,
Department of Periodontology,
Liaquat College of Medicine and Dentistry,
Dental Block, Darul Sehat Hospital, Karachi, Pakistan.
Email: dr_nt01@hotmail.com

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Source of Support: Nil

Conflict of Interest: None Declared

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