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Fri, 25 Jan 2002 19:55:36 EST

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In a message dated 1/25/2002 6:26:19 PM Eastern Standard Time, 
karim@trauma.org writes:

> to drain bile from the chest.  Ultrasound of the abdomen does not show any 
> collections.
>  
> Carry on waiting?
>  
> Most papers for non-op management of liver injuries do still advocate a CT 
> scan.  Are you relying on ultrasound alone for stable patients with normal 
> abdo exams?  
>  
> Karim
> 

This would be an indication for ERCP with stent placement, possibly with the 
addition of octreotide in an attempt to divert the bile down its normal 
pathway and allow the fistula to close off.  As to "most papers" advocating 
CT for liver injuries--I am not aware of any such paper in dealing with 
penetrating liver injury--you I believe are referring to blunt liver injury, 
and the two are quite different.  Don't interchange the two mechanisms.  In 
blunt liver injury, an initial CT is indicated just to make the diagnosis 
that a liver--or spleen--injury is what you are dealling with--nothing to do 
with the nature or extent of injury, as these latter factors are now known 
not to correlate with management.  In both cases, followup CT's are not 
necessary.  Anyway--we need to keep to the issue you presented--penetrating 
liver injury.  
Had you initially operated on this injury, it is entirely likely this bile 
leak would have occurred anyway, for anyone thinking of advancing that 
argument for initial operation--but probably would have leaked into the 
abdomen rather than the chest assuming the diaphragm would have been repaired 
at surgery (something not at all necessary)
ERF

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<HTML><FONT FACE=arial,helvetica><FONT  COLOR="#0000ff" SIZE=2 FAMILY="SCRIPT" FACE="Comic Sans MS" LANG="0"><B>In a message dated 1/25/2002 6:26:19 PM Eastern Standard Time, karim@trauma.org writes:<BR>
<BR>
</FONT><FONT  COLOR="#000000" style="BACKGROUND-COLOR: #ffffff" SIZE=2 FAMILY="SANSSERIF" FACE="Arial" LANG="0"></B><BR>
</FONT><FONT  COLOR="#0000ff" style="BACKGROUND-COLOR: #ffffff" SIZE=2 FAMILY="SANSSERIF" FACE="Arial" LANG="0"><BLOCKQUOTE TYPE=CITE style="BORDER-LEFT: #0000ff 2px solid; MARGIN-LEFT: 5px; MARGIN-RIGHT: 0px; PADDING-LEFT: 5px">to drain bile from the chest.&nbsp; Ultrasound of the abdomen does not show any collections.</FONT><FONT  COLOR="#000000" style="BACKGROUND-COLOR: #ffffff" SIZE=3 FAMILY="SANSSERIF" FACE="Arial" LANG="0"><BR>
 <BR>
</FONT><FONT  COLOR="#0000ff" style="BACKGROUND-COLOR: #ffffff" SIZE=2 FAMILY="SANSSERIF" FACE="Arial" LANG="0">Carry on waiting?</FONT><FONT  COLOR="#000000" style="BACKGROUND-COLOR: #ffffff" SIZE=3 FAMILY="SANSSERIF" FACE="Arial" LANG="0"><BR>
 <BR>
</FONT><FONT  COLOR="#0000ff" style="BACKGROUND-COLOR: #ffffff" SIZE=2 FAMILY="SANSSERIF" FACE="Arial" LANG="0">Most papers for non-op management of liver injuries do still advocate a CT scan.&nbsp; Are you relying on ultrasound alone for stable patients with normal abdo exams?&nbsp; </FONT><FONT  COLOR="#000000" style="BACKGROUND-COLOR: #ffffff" SIZE=3 FAMILY="SANSSERIF" FACE="Arial" LANG="0"><BR>
 <BR>
</FONT><FONT  COLOR="#0000ff" style="BACKGROUND-COLOR: #ffffff" SIZE=2 FAMILY="SANSSERIF" FACE="Arial" LANG="0">Karim</FONT><FONT  COLOR="#000000" style="BACKGROUND-COLOR: #ffffff" SIZE=3 FAMILY="SANSSERIF" FACE="Arial" LANG="0"><BR>
</BLOCKQUOTE><BR>
</FONT><FONT  COLOR="#0000ff" style="BACKGROUND-COLOR: #ffffff" SIZE=2 FAMILY="SCRIPT" FACE="Comic Sans MS" LANG="0"><B><BR>
This would be an indication for ERCP with stent placement, possibly with the addition of octreotide in an attempt to divert the bile down its normal pathway and allow the fistula to close off.&nbsp; As to "most papers" advocating CT for liver injuries--I am not aware of any such paper in dealing with penetrating liver injury--you I believe are referring to blunt liver injury, and the two are quite different.&nbsp; Don't interchange the two mechanisms.&nbsp; In blunt liver injury, an initial CT is indicated just to make the diagnosis that a liver--or spleen--injury is what you are dealling with--nothing to do with the nature or extent of injury, as these latter factors are now known not to correlate with management.&nbsp; In both cases, followup CT's are not necessary.&nbsp; Anyway--we need to keep to the issue you presented--penetrating liver injury.&nbsp; <BR>
Had you initially operated on this injury, it is entirely likely this bile leak would have occurred anyway, for anyone thinking of advancing that argument for initial operation--but probably would have leaked into the abdomen rather than the chest assuming the diaphragm would have been repaired at surgery (something not at all necessary)<BR>
ERF</B></FONT></HTML>

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