- Symptoms of Injuries of a liver
- Reasons of Injuries of a liver
- Treatment of Injuries of a liver
The injury of a liver concerns to the most serious on weight, complexity of recognition and treatment of diseases. According to our data, the frequency of the closed and open injuries of a liver at an injury of an abdominal cavity makes 20,5%. The injuries of a liver only closed occur at 18,7% of patients of the same group. The isolated injuries of a liver meet seldom (7,6%), in most cases (77,6%) injuries of a liver happen multiple and combined (an injury of other abdominal organs, the musculoskeletal device, a skull, etc.).
There are several classifications of the injuries of a liver considering a type of an injury, degree of a rupture of a liver and the nature of damages out of - and intra hepatic vessels and channels. The best, from our point of view, is the classification offered scientists:
I. The closed injuries of a liver:
1. On the injury mechanism: direct blow; falling from height; a prelum between two objects; road injury; gaps at a prelum abdominale tension; at newborns, and also the liver patholologically changed.
2. By the form damages: a rupture of a liver with damage of the capsule (chreskapsulyarny ruptures of a liver); subkamsulyarny hematomas; central gaps, or liver hematomas; damage of extrahepatic bilious ways and vessels of a liver.
3. On a damage rate: superficial cracks and gaps up to 2 cm in depth; gaps to a half of thickness of body; gaps depth more than a half of thickness of body and through gaps; razmoz-a zheniye of parts of a liver or a partition on separate fragments.
4. On localization: damage of shares or segments of a liver.
5. On character: damages with defeat out of - and intra hepatic vessels and bilious channels.
II. Open injuries of a liver (wound):
1. Fire: bullet, fragmental, shot.
2. Put with cold weapon: chipped and cut.
III. Combination of a stupid injury of a liver to wound.
The closed injuries of a liver. The reasons of an injury are various: falling about heights, a prelum, direct blow in a stomach.
The type of injuries of a liver depends on the injury mechanism. Bystry and strong influence (blow) on the limited site of a liver causes damage to a type of the center of crush and cracks. Strong impact on a significant area of a liver (a prelum at collapses, buffers of cars etc.) leads to extensive crush of body.
The closed injuries of a liver quite often (58,5%) are combined with injury of edges, a thicket of the V—VIII on the right, at the same time the condition of the patient worsens, especially at damage of bodies of a chest cavity (43,2%).
The right hepatic lobe (56,2%) is more often damaged, is more rare left (16,3%), portal fissures (10,9%), sheaves (6,8%).
Ruptures of a parenchyma with damage of the capsule (single and multiple cracks, crush of certain sites of a parenchyma, simultaneous injury of a liver, gall bladder and outside bilious channels) are characteristic of the closed injury of a liver. There is a rupture of fabric in a liver at the kept capsule (formation of a subcapsular hematoma) less often.
Emergence of cracks, gaps, hemorrhages leads to formation of focal necroses of a parenchyma of a liver.
In literature there are messages about "an explosive injury baking of "a traumatic hemobilia". Both of these complications are a consequence of accumulation of blood in the depth of a parenchyma of a liver and usually threaten the patient's life (a lethality from 32 to 50%).
Symptoms of Injuries of a liver:
The clinical picture of the closed injury of a liver is defined by the nature of injury of the liver and the accompanying damages of other bodies.
At injury of the liver symptoms of internal bleeding are most often observed. They are most expressed at massive blood loss which depends on character and localization of a rupture of body.
At the combined injury of a liver and hollow body the picture of internal bleeding and peritonitis develops. At the same time it is not possible to allocate any pathognomonic symptoms, especially at persons with the severe accompanying injury.
At the isolated closed injury of a liver two clinical options of a current — rather easy and heavier are possible.
At subcapsular hematomas and small injuries with disturbance of an integrity of the capsule the condition of the patient remains rather satisfactory. At considerable or multiple crushes and separations of fragments of a liver internal bleeding and traumatic shock cause serious condition of the patient, especially at the combined injuries of a liver.
The first and characteristic symptom at a liver injury — pain, from hardly notable to sharp, in the field of the right hypochondrium or in the place of a bruise. It is clear, that it sharply amplifies at a multiple injury, and also at an injury of several abdominal organs. At the isolated injury of a liver forced situation seldom meets (sedentary) at which change hurt amplify.
Big difficulties at establishment of the diagnosis arise at considerable intraperitoneal bleedings and shock of the II—III degree when the symptomatology is absent or is maleficiated. Careful survey of the patient allows to reveal local damages (grazes, hemorrhages according to a liver projection, fractures of edges) and helps to specify the diagnosis.
Frequency and filling of pulse at the closed isolated liver injury considerably change that can cause the wrong assessment of a condition of the victim. Dynamic observation of frequency and filling of pulse, and also complex assessment with other indicators are important; in particular with arterial pressure.
Arterial pressure usually the first minutes after an injury increases, with strengthening of bleeding — falls. Scientists consider that falling of arterial pressure happens after loss of 800 — 1500 ml of blood.
At survey directly after an injury the following comes to light: the stomach is pulled in, participates in the act of breath restrictedly (later the stomach happens to accession of paresis of intestines, it is blown up), at a palpation morbidity and tension, especially in right hypochondrium. At bleeding Kulenkampf's symptom (morbidity comes to light at soft or slightly intense abdominal wall). Shchetkin's symptom — Blyumberg is characteristic of the late period, during the first hours it comes to light only at 30% of patients. The dullness in sloping sites of a stomach appears also during the first hours after an injury because of blood accumulation.
Less often the phenomenon of movement of liquid in an abdominal cavity is defined. Scientists consider that its manifestation requires accumulation not less than 1 l of blood. However because of serious condition of the patient it is not always possible to reveal this symptom.
The fracture of the lower edges on the right with sharp morbidity in right hypochondrium and the expressed muscular protection can simulate injury of a liver.
Injuries of a liver with formation of a subcapsular or intra hepatic hematoma and the subsequent rupture of the capsule and bleeding in an abdominal cavity are subject to special consideration. These are double-stage, or two-phase, the ruptures of a liver called in foreign literature slowed down.
Subcapsular hematomas meet seldom. They are formed at capsule amotio (bleeding of small vessels), is more often on the phrenic surface of a liver.
At first patients are disturbed only by pains in the field of a bruise, the state remains satisfactory, the symptomatology is absent. Pain in 2 — 3 days can cease, however because of a hematoma the liver remains increased, acting from hypochondrium. Subfebrile temperature, a leukocytosis, sometimes slight jaundice are characteristic of this period. At the proceeding subcapsular bleeding, the slightest physical tension there are a rupture of the capsule and emptying of a hematoma in an abdominal cavity. There are symptoms of intra belly bleeding. Diagnosis of a hematoma is difficult, from the moment of education it and to a gap there can pass several days.
Naturally, the gap it is the absolute indication to operation. Isolated cases of subcapsular gaps are described.
Diagnosis of injuries of a liver presents the known difficulties, especially at the combined damages (craniocereberal, a backbone, a breast, a basin, extremities). The quantity of diagnostic mistakes makes 20 — 25%. With the advent of a laparocentesis, a laparoscopy and other methods of inspection of a mistake are observed much less often.
Reasons of Injuries of a liver:
Injuries of a liver are result of mechanical influence from the outside - falling, blows, etc.
Treatment of Injuries of a liver:
There is no basic distinction in tactics of the surgeon at the closed and open injuries of a liver. In both cases treatment can be only operational, and the operation, the better it outcomes is performed earlier. Operation at injury of a liver pursues three aims: ensuring good access to the damaged body, processing of a wound of a liver (a bleeding stop) and prevention of complications (development of peritonitis, late bleeding and a zhelcheistecheniye). It is preferable that operation under an intubation anesthesia with muscle relaxants was performed by crew from three surgeons.
Injury of a liver often is complicated by traumatic shock at which disturbance of functions of a number of vitals is observed: central nervous system, bodies of blood circulation, breath, endocrine system, etc. In this regard a foremost task of the surgeon and resuscitator is recovery of the broken functions of these systems.
First of all it is necessary to recover urgently the central blood circulation — to fill the lost volume of the circulating blood (to eliminate an oligemiya and to improve kislorodtransportny function of blood). At shock and the proceeding bleeding resuscitation actions of the surgeon consist in an immediate stop of bleeding that is reached by an operative measure.
Before operation it is necessary to make a kanyulyation not less than 2 veins, one of them — subclavial — a puncture, another — an upper vena cava — introduction to it of a polyvinyl chloride catheter. Through these kanyulirovanny veins perform infusion-transfusion therapy.
In the absence of effect of the held resuscitation events begun in the intravenous way it is necessary to pass to an intra arterial method.