Trauma to the liver may result in subcapsular or intrahepatic hematoma, contusion, vascular injury, or biliary disruption.

CT scanning, particularly contrastenhanced CT scanning (CECT), is accurate in localizing the focus and extent of hepatic injuries and associated trauma, providing vital information for treatment in patients. CT scanning without intravenous contrast enhancement is of limited value in hepatic trauma, but it can be useful in identifying or following up a hemoperitoneum. CT scan criteria for staging liver trauma based on the AAST liver injury scale include the following:

Grade 1 - Subcapsular hematoma less than 1 cm in maximal thickness, capsular avulsion, superficial parenchymal laceration less than 1 cm deep, and isolated periportal blood tracking Grade 2 - Parenchymal laceration 1-3 cm deep and parenchymal/subcapsular hematomas 1-3 cm thick Grade 3 - Parenchymal laceration more than 3 cm deep and parenchymal or subcapsular hematoma more than 3 cm in diameter Grade 4 - Parenchymal/subcapsular hematoma more than 10 cm in diameter, lobar destruction, or devascularization Grade 5 - Global destruction or devascularization of the liver Grade 6 - Hepatic avulsion

Adapted from:
J Trauma. 1995 Mar;38(3):323-4. Organ injury scaling: spleen and liver (1994 revision). Moore EE, Cogbill TH, Jurkovich GJ, Shackford SR, Malangoni MA, Champion HR.

CT scan findings include the following: Subcapsular hematoma - This is usually in a lenticular configuration with most subcapsular hematomas presenting anterolateral to the right lobe of the liver. Subcapsular hematomas cause compression and deformity of the underlying liver. Nonenhanced CT scans show the liver as hyperattenuating compared with a subcapsular hematoma. On CECT scans, a subcapsular hematoma appears as a low-attenuating, lenticular collection between the liver capsule and the enhancing liver parenchyma. Attenuation of the subcapsular hematoma decreases steadily over time and interval increase in the density suggests rebleeding. Subcapsular hematomas typically resolve in 6-8 weeks. Intraparenchymal hematomas - CECT shows acute hematomas as irregular, highattenuation areas, which represent clotted blood, surrounded by low-attenuating unclotted blood or bile. The density of the hematoma will reduced over time and the hematoma will form a well-defined serous fluid collection that may expand slightly. A focal, intrahepatic, hyperattenuating area with attenuation of 80-350 HU suggests an active hemorrhage or pseudoaneurysm.

Focal or diffuse low desnity in a periportal distribution is usually tracking of blood around the portal vessels. The differential considerations include:

Bile leaks Edema Dilated periportal lymphatics secondary to increased central venous pressure or injury to the lymphatics.

Pediatric periportal low-attenuation zones - Periportal low-attenuation zones have been seen in up to 15% of children following blunt trauma. The presence of these zones is associated with an intraabdominal injury (often hepatic or adrenal injury) in approximately 60%. Children with periportal low-attenuation zones, regardless of other evidence of intraabdominal injury, tended to be more physiologically unstable as judged by a lower Trauma Score. These zones have been associated with a significantly higher mortality rate of up to 13% versus 1% for children without this finding. (Sivit, et al., 1993)

Laceration - Laceration of the liver typically appears as peripheral nonenhancing linear or branching lesions. Acute lacerations have a sharp or jagged margin and may enlarge over time and develope "rolled" edges. Multiple parallel lacerations occur as result of compressive forces (bear claw lacerations). Lacerations may communicate with hepatic vessels and/or biliary radicles. Vascular injuries - Major hepatic veins and retrohepatic inferior vena cava trauma are uncommon after blunt abdominal trauma. Retrohepatic vena caval injuries are suggested on CT scans when lacerations extend into the major hepatic veins and the inferior vena cava or when profuse retrohepatic hemorrhage extends into the lesser sac or near the diaphragm. Perihilar liver tissue may become partially devascularized by a deep laceration or complete avulsion of the dual hepatic blood supply. These devascularized areas of the liver appear as wedge-shaped regions extending toward the liver periphery, and they fail to enhance after the administration of contrast material. Pseudoaneurysms are better depicted by using spiral or multisection CT scanning because of the ability to image during peak contrast enhancement. Acute hemorrhage - Acute, intrahepatic hemorrhage is seen as irregular areas of contrast agent extravasation. Measurement of attenuation values is useful in differentiating extravasated contrast from hematoma. Extravasated contrast material has an attenuation value of 85-350 HU (mean, 132 HU), whereas hemorrhage has an attenuation value of 40-70 HU (mean, 51 HU). CT scans can be useful in depicting recurrent bleeding after surgery or radiologic intervention.

Gallbladder injury - Gallbladder injury is uncommon, occurring in 2-8%, from blunt abdominal trauma, but is typically assciated with significant mortality. Hypovolemic shock may occur in reponse to bile within the peritoneal cavity. Prior to the availability of CT scanning and ultrasonography, gallbladder injuries were rarely diagnosed before surgery. CT findings in gallbladder injuries include:

Ill-defined or irregular wall contour Pericholecystic or subserosal fluid Collapsed gallbladder Wall thickening Intraluminal blood Free intraluminal mucosal flap Contrast enhancement of the gallbladder wall or mucosa Free intraperitoneal fluid iso-attenuating with bile Mass effect on the duodenum Displacement of the gallbladder toward the midline.

Biloma - A biloma may take weeks or months to develop after trauma. CT can demonstrate a cystic structure of low attenuation in or around the liver. When the source of the fluid is uncertain, consideration should be given to performing a HIDA scan which is exquisitively sensitive for bile extravasation. Bilomas may contain debris or septa which are best seen on ultrasound. Bile peritonitis is an uncommon but serious complication of blunt liver trauma. Bile peritonitis includes persistence or increasing amounts of low-attenuating, free peritoneal fluid and an enhancing thickened peritoneum. http://uvmrads.org/sections/bodyct/86-liver-lacerations-aast-criteria-and-examples? showall=1