Importance of focused assessment with sonography for trauma scan in abdominal trauma: Incidental finding of liver contusion in a case of maxillofacial injury - Ultrasonography and computed tomography imaging

Shreya Tapadia; Suresh Phatak; Varun Singh

doi:10.4103/jdmimsu.jdmimsu_38_20

CASE REPORT

Year : 2020 | Volume : 15 | Issue : 2 | Page : 303-305

Importance of focused assessment with sonography for trauma scan in abdominal trauma: Incidental finding of liver contusion in a case of maxillofacial injury - Ultrasonography and computed tomography imaging

Shreya Tapadia, Suresh Phatak, Varun Singh
Department of Radio Diagnosis, Jawaharlal Nehru Medical College, Datta Meghe Institute of Medical Sciences (Deemed to be University), Sawangi (Meghe), Wardha, Maharashtra, India

Date of Submission	05-Feb-2020
Date of Decision	15-Feb-2020
Date of Acceptance	10-Mar-2020
Date of Web Publication	21-Dec-2020

Correspondence Address:
Dr. Suresh Phatak
Department of Radio Diagnosis, Jawaharlal Nehru Medical College, Sawangi (Meghe), Wardha - 442 001, Maharashtra
India

Source of Support: None, Conflict of Interest: None

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DOI: 10.4103/jdmimsu.jdmimsu_38_20

Abstract

FAST scan is an important constituent of imaging in case of trauma. We are presenting a case of maxillofacial trauma without any external abdominal injury, in whom liver trauma was incidentally diagnosed on focused assessment with sonography for trauma scan. Ultrasonography and computed tomography features of liver trauma are discussed.

Keywords: Computed tomography scan, focused assessment with sonography for trauma scan, liver trauma, ultrasonography

How to cite this article:
Tapadia S, Phatak S, Singh V. Importance of focused assessment with sonography for trauma scan in abdominal trauma: Incidental finding of liver contusion in a case of maxillofacial injury - Ultrasonography and computed tomography imaging. J Datta Meghe Inst Med Sci Univ 2020;15:303-5

How to cite this URL:
Tapadia S, Phatak S, Singh V. Importance of focused assessment with sonography for trauma scan in abdominal trauma: Incidental finding of liver contusion in a case of maxillofacial injury - Ultrasonography and computed tomography imaging. J Datta Meghe Inst Med Sci Univ [serial online] 2020 [cited 2021 Jan 23];15:303-5. Available from: http://www.journaldmims.com/text.asp?2020/15/2/303/304260

Introduction

In developing nations, under the age of 45 years, the major cause of death and disability is trauma.^[1] Organ that is involved frequently is spleen followed by the liver.^[2] Deceleration injuries cause the majority of trauma.^[3] Following a history and clinical examination, a precise initial diagnostic imaging modality is needed for which ultrasonography is useful.^[4] As its readily available, it requires minimal preparation time and is a mobile equipment integral to the emergency department^[5] FAST technique is a rapid test that sequentially surveys the pericardial region, and then the right and left upper quadrants and pelvis.^[6] Findings suggestive of positive FAST include: The presence of fluid in at least one of the three spaces – pericardial (hemopericardium), pleural (hemothorax), and peritoneal (hemoperitoneum, urine-bladder injury, bile-gall bladder injury, and bowel contents^[1] computed tomography (CT) is the modality of choice for confirming findings on FAST.^[7]

Case Report

A 25-year-old hemodynamically stable male patient was brought to the emergency department after maxillo-facial injury. The patient was advised emergency CT scan imaging of the head which revealed multiple maxillo-facial fractures with normal brain parenchyma. The patient had no abdominal complaints and no external visible abdominal injuries. However, according to the Advanced Trauma Life Support protocol the patient was sent for focused assessment with sonography for trauma (FAST) examination-There was evidence of free fluid noted in the pelvis and Morrison's pouch with internal echo's within which suggested of hemoperitoneum [Figure 1]. On a Grey-scale ultrasound imaging, there was an ill-defined heterogeneously hyperechoic area noted in the right lobe of the liver, measuring −10.1 cm × 7 cm in size suggestive of liver contusion [Figure 2]. This was followed by a contrast-enhanced computed tomography study to confirm the sonography findings, the study revealed an ill-defined, heterogeneously hyperdense lesion with peripheral hypodensity in segment VI, VII, and VIII of the right lobe of the liver approximately measuring 10.1 cm × 7.4 cm × 5.3 cm with a HU value of 56 suggestive of liver contusion [Figure 3]a and [Figure 3]b.

Figure 1: Gray-scale ultrasound imaging showing evidence of free fluid in the pelvis with internal echo's suggestive of hemoperitoneum

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Figure 2: Gray-scale ultrasound imaging showing an ill-defined heterogeneously hyperechoic area in the right lobe of the liver

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Figure 3: (a) Nonenhanced computed tomography, (b) contrast-enhanced computed tomography: ill-defined, heterogeneously hyperdense lesion with peripheral hypodensity in segment VI, VII, and VIII of the right lobe of the liver having HU value of 56 s/o liver contusion

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Discussion

In abdominal blunt trauma cases, the most affected part in the liver is the right lobe as it is the most voluminous portion of the liver and posterior–superior hepatic segments as they are proximal to fixed structures such as ribs and spine which get involved in blunt trauma.^[2] Ultrasonography identifies intraperitoneal collections of free fluid, a minimum of about 200 mL of fluid is required (Morrison pouch, the pouch of douglas, and splenorenal fossa). Sensitivity of FAST increases with increasing volumes of free fluid.^[8]

Multi detector-row CT helps in the detection of delayed complications.^[3] The American Association for the Surgery of Trauma classifies liver trauma according to the severity on CT scan imaging. Grade I-sub capsular hematoma more than 10% surface area, laceration of more than 1 cm parenchymal depth. Grade II-subcapsular hematoma 10%–50% surface area or intraparenchymal hematoma: more than 10 cm diameter or laceration of 1–3 cm parenchymal depth, more than 10 cm length. Grade III-sub capsular hematoma: More than 50% surface area of ruptured subcapsular or parenchymal hematoma or intraparenchymal hematoma: More than 10 cm or laceration of more than 3 cm parenchymal depth and vascular injury with active bleeding contained within the liver parenchyma. Grade IV-laceration: Parenchymal disruption involving 25%–75% hepatic lobe or involves 1–3 Couinaud segments or vascular injury with active bleeding breaching the liver parenchyma into the peritoneum. Grade V-laceration: Parenchymal disruption involving >75% of hepatic lobe or vascular: Juxtahepatic venous injuries (retro hepatic vena cava/central major hepatic veins). According to this classification our case was diagnosed as Grade III liver injury.^{[9],[10],[11],[12],[13],[14]}

Declaration of Patient Consent

The authors certify that they have obtained all appropriate patient consent forms. In the form the patient(s) has/have given his/her/their consent for his/her/their images and other clinical information to be reported in the journal. The patients understand that their names and initials will not be published and due efforts will be made to conceal their identity, but anonymity cannot be guaranteed.

Conclusion

Hence, performing FAST in a patient who has undergone trauma even without any external abdominal injuries and complaints helps us in identifying liver injuries which are confirmed on CT imaging. This helps surgeons to make rapid decisions for the management.

Financial support and sponsorship

Nil.

Conflicts of interest

There are no conflicts of interest.

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