Liver Trauma Case
	Date: Tue, 20 Aug 1996 10:06:52 From: Philip Peverada [peverada@MIDCOAST.COM] Two weeks ago, I saw a 29 yo w male involved in an MVA. No witnesses or history of what happened except that he was very drunk. Initially BP was 70 P 88. After 1500 cc of RL his BP was 120, P 80. He had abrasions over the RUQ and a fxd L tenth rib. CT showed a large hemoperitoneum with a Grade III liver laceration. I watched him, transfused two units of PRBC'c on day 4 for a Hct of 19 and d/c'd him on day ten. He had one temp spike of 101 on day 5 and evidence of a R pleural effusion that I tapped for 1500 cc of old bloody fluid. He returned on the 13th post trauma day with a fever of 101.6, a large r pleural effusion and a WBC of 16,000. After fluid, WBC was 9,000, CT showed less intrabdominal fluid and a healing liver. Thoracentesis showed the same bloody fluid with a Bilirubin of 20. HIDA scan shows a small leak in the liver collecting in the LUQ. I can't find much written on Bile leaks in this situation. My inclination is to watch him as he is stable and afebrile. Any comments?
	Date: Tue, 20 Aug 1996 15:38:34 From: Bruce Bodnor [Bebgsurg@AOL.COM] Bravo for your restraint and steadfast clear thinking with this patient. It is so easy to be rushed to "operate!" on blunt trauma, then find a very hard to manage liver laceration that could have been left alone to tamponade. Now I guess you could wait, though I suspect a CT guided drain will be needed, and more waiting.
	Date: Tue, 20 Aug 1996 20:56:25 From: Moshe Schein [mschein@planet.earthcom.net] Your treatment of this patient was excellent and according to the modern literature. Indeed, there is much written about the management of delayed complications following conservative Rx of blunt liver trauma, A recent article in (?Ann Surg or J Trauma; sorry all my references are in the office) was dedicated to this topic (i.e. delayed complications). Bilomas, such as occuring in your patient should be (initially at least) managed percutaneously. If there is still a collection I would insert a pigtail and watch. Serial CT with contrast is indicated, also to watch for the relatively common associated false aneurysms of injured hepatic artery branches.
	Date: Tue, 20 Aug 1996 23:14:06 From: ALLEN YEO WAN YAN [allenyeo@MSN.COM] I read with interest the conservative management of this patient with liver trauma. I noticed that the side of the grade III liver injury was not mentioned. Is it on the right as is consistent with the RUQ abrasion or is it on the left as is consistent with a left 10th rib fracture? What worried me most was the presence of the large right pleural effusion (bloody) which recurred on his readmission. Could this be hiding an underlying diaphragmatic injury? Also can the bilirubin of 20 exclude the abdomen as the origin of the pleural fluid? Thanks for the opportunity to take part in this discussion.
	Date: Thu, 22 Aug 1996 11:28:37 From: Philip Peverada [peverada@MIDCOAST.COM] Thanks for the reference. I will check out the library. I have been scanning with IV contrast. I assume that will be sufficient to pick up an aneurysm? The laceration was through the falciform ligament area heading medially. Bile seems to be coming from the left lobe. I also have been concerned re a diaphragmatic rupture, but so far haven't found one. The fluid in the left chest hasn't returned yet, so I'm hoping this is all a slowly resolving process related to the severity of the original trauma. I will let you know how things resolve.
	Date: Fri, 23 Aug 1996 15:06:10 From: John A. Aucar, M.D. [jaucar@bcm.tmc.edu] I don't mind the thought of watching a bile leak as long as there a route for drainage. A small fistula will probably close and if doesn't, you can close it. I would be a little worried about an undrained bile collection. Those are bad enough when they aren't infected and real trouble when they are. Also, do you have any concern about a hole in the diaphragm? Did a nearby rib fracture puncture both the diaphragm and liver? Chances are, by the time you read this, his pleural bilious effusion has recollected you placed a chest tube and he now has a hepato-pleural-cutaneous fistula (hope not). Some would have a low threshold for surgery in these cases and that's probably OK (purposefully non-committal). Good luck.
	Date: Thu, 22 Aug 1996 22:07:29 From: Paul G. Jenko, MD [pjenko@watsonclinic.com] Although I'm not aware of direct anatomic classification, it seems interesting that a few apparently horrific lacerations actually have very little blood loss. I can recall one where the liver was split open like a book - right down to the IVC, which appeared bare anteriorly on CT scan. Surprisingly little blood, and the lesion healed uneventfully.
	Date: Fri, 23 Aug 1996 19:44:43 From: Ken Mattox [KMATTOX@aol.com] I would at least percutaneously drain the LUQ collection. I would have operated upon him prior to the second unit of blood.