Liver Injury Grading

Assigns an AAST grade of liver trauma severity based on hepatic hematoma and degree of laceration.

In the text below the tool there is more information about the six liver injury grades.

The liver injury grading tool evaluates the severity of traumatic liver injury based on characteristics of the hepatic hematoma and laceration.

The six grades used are the ones from the American Association for the Surgery of Trauma (AAST).

5% of all trauma presentations with abdominal injury consist of liver trauma, either blunt or penetrating.

Diagnosis is put based on presentation symptoms (pain and tenderness in the right abdominal quadrants, signs of shock due to haemorrhage) and ultrasound and computer tomography investigations.

All patients receiving a grade higher than II are likely to require surgical procedure to contend the haemorrhage. Most liver trauma associated mortality is caused by exsanguination.

  ■ Haematoma: subcapsular, <10% surface area;
  ■ Laceration: capsular tear, <1 cm depth.
  ■ Haematoma: subcapsular, 10-50% surface area;
  ■ Haematoma: intraparenchymal <10 cm diameter;
  ■ Laceration: capsular tear, 1-3 cm depth, <10 cm length.
  ■ Haematoma: subcapsular, >50% surface area, or ruptured with active bleeding;
  ■ Haematoma: intraparenchymal >10 cm diameter;
  ■ Laceration: capsular tear, >3 cm depth.
  ■ Haematoma: ruptured intraparenchymal with active bleeding;
  ■ Laceration: parenchymal disruption involving 25-75% hepatic lobes or involves 1-3 Couinaud segments (within one lobe).
  ■ Vascular: juxtahepatic venous injuries (inferior vena cava, major hepatic vein);
  ■ Laceration: parenchymal disruption involving >75% of hepatic lobe or involves >3 Couinaud segments (within one lobe).
  ■ Vascular: hepatic avulsion;
  ■ Laceration present or not.
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AAST liver injury grades

This is a 6-item liver laceration grading scale based on the guidelines of the American Association for the Surgery of Trauma.

This offers information about the severity of liver trauma, in terms of hematomas and lacerations. A similar scale exists for splenic lacerations.

The following table summarizes the six AAST liver injury grades:

Grade Hematoma Laceration
I Subcapsular, <10% surface area Capsular tear
II Subcapsular, 10-50% surface area;
Intraparenchymal		 Capsular tear, 1-3 cm depth
III Subcapsular, >50% surface area, or ruptured with active bleeding;
Intraparenchymal >10 cm diameter		 Capsular tear >3 cm depth
IV Ruptured intraparenchymal with active bleeding Parenchymal disruption involving 25-75% hepatic lobes or involves 1-3 Couinaud segments (within one lobe)
V Juxtahepatic venous injuries (inferior vena cava, major hepatic vein) Parenchymal disruption involving >75% of hepatic lobe or involves >3 Couinaud segments (within one lobe)
VI Hepatic avulsion Present or not

As described in the above table, the degrees of liver injury vary, with I being the least severe and VI being the most severe.

The rule is that almost all injuries classified higher than grade II will require some form of surgical correction and, in some cases, preparation for blood transfusion.

According to the National Trauma Data Bank (NTDB), most presentation are given one of the first three grades.

 

Liver trauma guidelines

5% of all trauma presentations with abdominal injury consist of liver trauma, either blunt or penetrating. Because of its abdominal position and the large surface it covers, the liver is prone to stab wounds and shooting wounds due to the abdominal position and the large surface covered.

Presentation includes pain and tenderness in the right abdominal quadrants with pain irradiating to the right shoulder.

Due to the intense vascularisation of this organ, most traumas are accompanied by bleeding in the abdominal cavity. If bleeding is present, the patient will also exhibit symptoms of shock, rapid heart rate, pale or bluish skin and cold teguments.

Hepatic injury ranges from hematomas to large ruptures. The first are described as a collection of blood, of different size and shape, in different locations. Lacerations of the liver tissue can be of different depths.

Diagnosis is based on ultrasound and computer tomography investigations which provide information about the shape and damage of the injury and the bleeding sources.

Hemodynamically unstable patients are usually referred for a FAST scan (focused assessment with sonography for trauma).

There are no laboratory tests specific for liver trauma but the standard ones can indicate signs of distress that are caused by trauma, for example, an elevated white blood cell count. Anemia, following post-traumatic haemorrhage usually has a delay in installation.

 

References

1. Bouras AF, Truant S, Pruvot FR. Management of blunt hepatic trauma. J Visc Surg. 2010; 147(6):e351-8.

2. Ahmed N, Vernick J. Management of liver trauma in adults. J Emerg Trauma Shock. 2011; 4(1): 114–119.

3. Yoon W, Jeong YY, Kim JK, Seo JJ, Lim HS, Shin SS, Kim JC, Jeong SW, Park JG, Kang HK. CT in blunt liver trauma. Radiographics. 2005; 25(1):87-104.

4. Stracieri LD, Scarpelini S. Hepatic injury. Acta Cir Bras. 2006; 21 Suppl 1:85-8.

Specialty: Hepatology

System: Digestive

Objective: Evaluation

No. Of Items: 6

Article By: Denise Nedea

Published On: July 8, 2017 · 07:05 AM

Last Checked: July 8, 2017

Next Review: July 8, 2023