Presentation
Patient with history of car vs bicyclist accident. The patient was entrapped beneath the motor vehicle and suffered severe abdominal and pelvic blunt trauma. BP: 35/22 and Glasgow scale: 4 at his arrival to the ER.
Patient Data
- there are multiple lacerations/fractures involving the porta hepatis as well as segment 1,4, 5 & 8, most of the them extending through the whole width of the affected area and reach the peripheral hepatic margins. Active contrast extravasation noted centrally adjacent to the porta hepatis, indicating an active bleeding. Small amount of branching gas attenuation seen within segment 8. Diffuse hypo-enhancement of the liver parenchyma is also present.
- massive amount of free fluid within the abdomen and pelvis (hemoperitoneum).
- mild thickening with prominent enhancement of the wall of small bowel loops in the center of the abdomen (shock bowel).
- collapsed inferior cava along its course.
- small caliber of the abdominal aorta.
- hyper-enhancing pancreas with extensive retroperitoneal edema/fluid.
- hyper-enhancing adrenal glands.
- hypo-enhancing spleen and kidneys, with visible enhancement of the arcuate arteries and main renal arteries.
Case Discussion
The case illustrates two important concepts:
Grade VI hepatic injury: lacerations involving the whole width of the affected region.
Most of the features of CT hypotension complex including (hypo-enhancement of solid organs, collapsed IVC, decreased caliber of the aorta, hyper-enhancing adrenals, thickening and hyper-enhancing of the bowel walls (previously shock bowel).
The patient was unstable when he arrived at the ER and had an episode of cardiac arrest. After proper resuscitation in the ER, the patient underwent a CT scan and after that he transferred immediately to the OR.
According to the surgery report, the patient suffered from an extensive liver laceration along the course of the middle hepatic vein and many smaller branching lacerations mainly involving the right lobe with injury to the retro-hepatic IVC. The patient underwent right hepatic lobectomy and the retro-hepatic cava injury was repaired. However, despite all the efforts to save the patient, he continued to be hemodynamically unstable and died on the next day of his admission.
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