Angiographic Diagnosis of Hepatic Rupture

Advance in the surgical ability to treat hepatic rupture has surpassed the diagnostic effectiveness of exploratory laparotomy. This frustrating situation has been aptly expressed by Solheim: “The damage to the liver parenchyma may be diffuse and vary widely in extent. A superficial defect in closed liver injuries may be merely an outward sign of general intrahepatic damage of unknown and varying extent, and it is this which threatens the patient's life. Consequently laparotomy affords little prospect of assessing the prognosis, however well the visible liver damage seems to have been sutured” (11). Hepatic trauma is attended by high morbidity and mortality rates, despite the fact that its incidence is highest in the vigorous young male. One-third of those incurring hepatic injuries do not survive long enough to receive treatment. The immediately fatal injuries are characteristically multiple and are commonly accompanied by laceration of the heart and aorta (75 per cent). Another third succumb from the injuries while hospitalized; the remaining third recover (11, 12). Many patients are so severely injured that a roentgen examination of any type is not warranted. When an adequate study can be carried out, valuable indirect evidence of liver damage may be demonstrated. The indirect roentgen signs of hepatic trauma have been thoroughly discussed by Frimann-Dahl and McCort (3, 5). An early definitive diagnosis cannot be established in a significant number of hepatic injuries by clinical methods and indirect roentgen studies. A direct method of diagnosis is needed. Burke and Madigan (2) in 1933 employed an intravenous injection of Thorotrast to demonstrate a rupture of the liver, but the dangerous side-effects of this contrast agent exclude its usage. Hepatic angiography is a direct diagnostic method showing various lesions within the liver. This presentation points out its usefulness in demonstrating the various findings in different types of blunt hepatic rupture. Angiographic Findings The following findings have been observed in the authors' 5 patients: 1. Displacement of the normal vasculature in the form of (a) circumferential displacement (Figs. 1 and 2), (b) crowding (Figs. 1 and 4), (c) straightening (Fig. 5), and (d) elongation (Figs. 1 and 2) 2. Accumulation of contrast medium within the hepatic substance, which may be (a) localized about a lesion (Fig. 3) or (b) diffuse (Fig. 4, B) 3. Accumulation of contrast medium in the peripheral portal vein radicles or biliary ducts (Fig. 5, B) 4. Secondary displacement of adjacent abdominal viscera (Fig. 1, C). One or more of these changes have been observed in the following lesions. Intraparenchymal hematoma is demonstrated by circumferential displacement of the hepatic arteries about the hematoma (Fig. 1 A, C). There may be an associated accumulation of contrast medium in the surrounding traumatized tissue.