Scandinavian Journal of Surgery 92: 192–194, 2003

EPIDEMIOLOGY OF LIVER INJURIES

P. Talving1, M. Beckman2, T. Häggmark1, L. Iselius1

1 Karolinska Hospital Trauma Centre, Department of Surgery, Karolinska Hospital,
Stockholm, Sweden
2 Department of Radiology, Karolinska Hospital, Stockholm, Sweden

ABSTRACT

Background and Aims: The aim of this study was to investigate the epidemiology of
liver injuries and to grade injuries according to the Organ Injury Scale in a population-
based study in Stockholm County comprising 1.75 million inhabitants.
Material and Methods: Cases were retrieved from the National Board of Forensic Med-
icine and Public Health and Medical Services Committee Register. Autopsy reports and
patients files were studied for liver injuries, associated injuries, age, sex, trauma mech-
anism, location of the injury, description of the injury, diagnostic and treatment modal-
ities when available.
Results: The incidence of traumatic liver injury in 1996 and 1997 was 2.95/100 000 an-
nually. Seventy seven autopsies with liver injuries revealed injury pattern of grade I in
6 cases (8 %), grade II in 10 cases (13 %), grade III in 21 cases (27 %), grade IV in 15 cases
(19 %), grade V in 16 cases (21 %) and grade VI in 9 cases (12 %). Twenty four patients
revealed injury pattern of grade II in 13 cases (46 %), grade III in 4 cases (14 %), grade
IV in 5 cases (18 %) and grade V in 2 cases (7 %).
Conclusions: The results demonstrate a low incidence of liver injuries in the studied
population. Grade II and III injuries prevail. Surgical management of liver injuries is
an infrequent treatment option in Stockholm County and simple operative measures
were applied. No complex hepatic injuries were operated upon.
Key words: Liver injuries; hepatic injuries; epidemiology; population study

INTRODUCTION of increasing healthcare costs, there is a need for

Injuries are the third leading cause of death world-
wide, causing more than five million deaths annual-
ly (1). Injuries constitute the leading cause of death
among children, adolescents and young adults aged
1 to 44 years (2).
In patients with abdominal trauma, the liver is the
most frequently injured organ (3). In the current era
Correspondence:
Peep Talving, M.D.
Department of Surgery
Karolinska Hospital
SE - 171 76 Stockholm, Sweden
Email: peep.talving@ks.se
more accurate epidemiological data to determine the
incidence of specific traumatic injuries in the popu-
lation. An accurate and detailed understanding of the
epidemiology of injuries leads to more accurately tar-
geted measures of prevention, diagnostic algorithms,
education and capital investment management.
The aim of this study was to investigate the epi-
demiology of liver injuries in a population-based
study in Stockholm County comprising 1.75 million
inhabitants.
MATERIAL AND METHODS
The study protocol was applied for the two consecutive
years of 1996 and 1997. Data were retrieved from two sep-
 Epidemiology of liver injuries 193

arate sources. Firstly, from the archives of the National TABLE 1

Board of Forensic Medicine (NBFM), Department of Foren-
Mechanism of injury.
sic Medicine in Stockholm for medico-legal autopsy re-
ports. All the autopsies associated with external causes of
Mechanism Number of Number of
injuries with a potential for traumatic liver injury were in- autopsies (%) patients (%)
cluded in the search. Autopsy reports were studied in de-
tail for liver injuries. Associated injuries, age, sex, trauma Fall 34 (43) 5 (18)
mechanism, site of the injury and a description of the in- Train accident 19 (24) 3 (11)
jury were documented when available. Liver injuries were Motor vehicle accident 12 (15) 1 0(3)
scored according to the Organ Injury Scale (4). Gunshot 02 0(3) 0 0(0)
Secondly, data on patients treated at Stockholm Coun- Stabbing 03 0(4) 3 (11)
ty’s emergency health care facilities for liver injuries were Automobile v. pedestrian 02 0(3) 2 0(7)
retrieved from the Public Health and Medical Services Motorcycle accident 01 0(1) 3 (11)
Riding accident 00 0(0) 2 0(7)
Committee (PHMSC) Register. Liver injuries were defined Crushing injuries 02 0(3) 0 0(0)
according to International Classification of Diseases (ICD), Bicycle accident 02 0(3) 2 0(7)
9th revision, for 1996 (864A, 864B) and according to ICD, Other* 01 0(1) 7 (25)
10th revision, for 1997 (S36.0, S36.1). To exclude non-trau-
matic or iatrogenic liver injuries, the diagnostic code had * Other: recreational 2, assault 2, boltgun injury 1, unknown 3.
to be associated with a supplementary classification code
for external causes of injury with the potential for hepatic
injury. Details about liver injuries were retrieved from op-
eration notes and computed tomographic and ultrasound
studies. Radiology studies were reviewed by a trauma ra- TABLE 2
diologist and resulted in scoring of the injuries according
to the Organ Injury Scale. Associated data retrieved includ- Organ injuries as a cause of death in autopsy group (n = 78).
ed age, sex, mechanism of injury, associated injuries, site
of the injury, a description of the injury and diagnostic and Injured organs Number of organs (%)
treatment modalities when available. An adult population
(minimum age of 15 years) was included and the index Brain 47 0(60)
cases had to be inhabitants of Stockholm County to be in- Lung 46 0(59)
cluded in the study. Heart 42 0(54)
The study was approved by the Research Ethics Com- Aorta 32 0(41)
Multiple organs 78 (100)
mittee of the Karolinska Institute at Karolinska Hospital.

RESULTS

The National Board of Forensic Medicine produced

TABLE 3
276 autopsy reports. All of the 276 autopsy reports
were reviewed and 78 autopsies with liver injuries Hepatic injury severity.
were identified, 39 autopsies for 1996 and 39 for 1997.
Patients with liver injuries were predominantly Organ injury scale Number of Number of
autopsies (%) patients (%)
males (59 males and 19 females). The ages ranged
from 18 to 93, with an average age of 47 years for Grade I 06 0(8) 00 0(0)
the group. The dominant injury site was the right Grade II 10 (13) 13 (46)
hepatic lobe in 32 cases (41 %). The left lobe was in- Grade III 21 (27) 04 (14)
jured in 7 cases (9 %) and bilobar injury was observed Grade IV 15 (19) 05 (18)
Grade V 16 (21) 02 0(7)
in 28 cases (36 %). The remaining 11 (14 %) autopsy Grade VI 09 (12) 00 0(0)
reports did not specify the injury site. A penetrating
trauma as the cause of the liver injury was found in
6 cases (8 %). The rest of the 72 autopsies (92 %) were
reported to have blunt trauma as the cause of the
liver injury. Liver injuries were caused predominant-
TABLE 4
ly by falls 34 (44 %) and train accidents 19 (24 %)
(table 1). All the autopsy cases had multiple organ Incidence of associated abdominal injuries.
systems injured. The causes of death were predomi-
nantly CNS injuries and pulmonary injuries (table 2). Organ Number of Number of
Liver injuries in this population group were grad- autopsies (%) patients (%)
ed in 77 out of 78 cases (99 %) (table 3). Associated Spleen 23 (29) 0
abdominal injuries were identified in 54 cases (70 %). Kidney 15 (19) 7 (25)
The most frequently injured organs were the spleen Diaphragm 10 (13) 0
and the kidney (table 4). Haemoperitoneum was Mesentery 07 0(9) 0
Stomach 03 0(4) 0
found in 8 autopsy reports (10 %). Bladder 02 0(3) 0
The PHMSC Register produced 28 patients with Small bowel 02 0(3) 0
traumatic liver injuries treated in the county’s emer- Duodenum 02 0(3) 0
gency hospitals in 1996 and 1997, 13 and 15 cases, Pancreas 02 0(3) 0
Multiple organs 09 (12) 0
respectively. Patients with liver injuries were pre-
194 P. Talving, M. Beckman, T. Häggmark, L. Iselius
dominantly males (19 males and 9 females). The ages
ranged from 16 to 71, with an average age of 34 years.
The predominant injury site was the right hepatic
lobe in 16 cases (57 %). The left lobe was injured in
3 cases (11 %) and bilobar injury was observed in
3 cases (11 %). One patient had a central hepatic in-
jury and the remaining 5 investigations (18 %) indi-
cated an unspecified injury site. A penetrating trau-
ma was found to be the cause of the liver injury in
3 cases (11 %) and blunt trauma in 23 cases (82 %).
In two cases (7 %) the files did not specify the injury
mechanism. Traffic accidents caused 12 of the liver
injuries (43 %) and falls 5 (18 %) in the group (ta-
ble 1).
Liver injuries in this population group were grad-
ed in 24 cases (86 %) (table 3). In 4 patients (14 %),
there were insufficient data for grading. Seven pa-
tients (25 %) had associated abdominal injuries (ta-
ble 4). Haemoperitoneum was found in 10 patients
(36 %). Two patients with grade II and one patient
with grade IV injuries arrived at the hospital in a
hypotensive state and two of the patients died of pul-
monary haemorrhage.
The diagnosis of liver injury was confirmed in
15 cases (54 %) by computed tomography, in 3 (11 %)
by ultrasound, in 5 (18 %) by both diagnostic modal-
ities and in 2 cases (7 %) by surgical exploration. In
3 cases (11 %), the details were not given in the files.
Fifteen (54 %) patients were treated non-operativ-
ely. Nine patients (32 %) were surgically explored.
Three of the operated patients (30 %) had a stab
wound as the cause of injury. The remaining operat-
ed 6 patients (70 %) suffered blunt trauma. Seven
therapeutic explorations were managed with liver
sutures and haemostatic agent applications and in
one of these, with placement of a common bile duct
drainage because of biliary leakage and peritonitis as
a late complication. One non-therapeutic explorative
laparoscopy and one non-therapeutic explorative
laparotomy were performed. Two patients were
treated with percutaneous drainage for large quanti-
ty hemoperitoneum and, in two patients, data on
treatment were not found. Two patients died due to
bleeding from pulmonary injuries, giving a mortali-
ty of 7 % in the patient group.
The incidence of traumatic liver injury in 1996 and
1997 was 2.95/100 000 annually.
DISCUSSION
To our knowledge, no previous population-based
study has been published on traumatic liver injuries.
Our results demonstrate a low incidence of liver in-
juries in the Swedish metropolitan population. Blunt
trauma was the predominating trauma mechanism
in the study population. The overwhelming bulk of
liver injuries were caused by falls and train accidents
with a massive injury pattern. The predominant in-
jury site was the right hepatic lobe. Liver injuries
were graded most frequently as grades II and III. The
majority of the hepatic injuries were managed non-
operatively. Out of nine laparotomies in total, seven
were considered therapeutic. The majority of the
measures were hemostatic in our series. Liver inju-
ries were managed by simple measures as parenchy-
mal sutures, topical hemostatic agents and drainage.
There were no complex hepatic injuries treated op-
eratively. Mortality in the patients group was relat-
ed to pulmonary complication and not directly to
liver injuries. Surgical management of liver injuries
is an infrequent treatment option in Stockholm Coun-
ty. Modern treatment options such as selective arte-
riography and transcatheter embolization (SATE)
(6, 8) and endoscopic retrograde cholangiopancrea-
tography (ERCP) (5, 6, 7, 9) will further reduce the
operative management of liver injuries.
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Received: September 19, 2002
Accepted: June 10, 2003