We report the case of a 31-year-old man in whom, in the context of a polytrauma due to traffic accident and after radiological assessment at admission (CT), there is evidence of hematoma affecting the hepatic hilium volume VII.
When hemodynamic stability and stable constants are present, a conservative attitude regarding liver trauma is maintained.
During his stay in the ICU, he presents elevated liver enzymes with AST and ALT values around 1,200 IU/l and rising bilirubin.
Controls did not show significant changes or obstruction of the intrahepatic or extrahepatic bile duct that could explain the elevation of enzymes of colostasis.
On the 7 day of ICU stay, the patient presented with fever, increasing leukocytosis, with suspicion of recurrent liver hematoma.
The clinical picture is resolved with empirical antibiotic treatment showing progressive decrease of liver enzymes to normal values.
In control CT, the objective is to reduce the volume of the hematoma, presenting a diameter of 6 cm, but air bubbles are identified with a wide variety of antibiotics. It is suggested that overinfection of the collection will continue, achieving normal coverage.
A new control CT scan showed an increase in the size of the lesion, with a diameter of 9.3 cm, of fundamentally liquid content, including fat densities.
Because of the increased size of the hepatic collection, it was decided to intervene in the patient, discarding percutaneous puncture due to the possibility of a hematoma with active bleeding.
During surgery, the presence of a biloma is observed, encompassed by the greater omentum, which displaces the hepatic angle of the colon, dependent on the liver (segments IV and V) and hemostasis zone customized to the wall.
The evolution was favorable, being discharged on the 10th postoperative day.
1.
As described in different studies (1.2), most authors recommend that the initial management of liver trauma be conservative, provided that hemodynamic stability can be maintained.
While patients with liver trauma associated with lesions in other organs require surgery, given the high mortality that presents conservative management (1).
At our center, the decision to maintain conservative treatment depends not only on the degree of liver trauma, but to a large extent on the hemodynamic status of the patient, always maintaining an overall assessment of the patient.
Regarding the diagnosis of biloma, its radiological appearance (CT or MRI) is that of a homogeneous and well-defined focal cystic lesion without septa or calcifications inside (3).
Although abdominal echography is useful for the diagnosis of choice intrahepatic and extrahepatic, contrast-enhanced abdominal CAT scan is today the exploration of choice for the diagnosis of complications derived from intrahepatic biliary lesions alone and its resolution.
MRI shows findings that are similar to those of CT, although MR cholangiography can help identify biliary duct lesions (5).
TAC-guided external drainage is currently considered the treatment of choice (6).
ERCP with sphincterotomy and stent placement are reserved for cases with maintained biliary fistula.
Surgery, in these cases, is usually an uncommon form of resolution, since it increases morbidity, obtaining similar results.
1.
Gómez, J. M. Álamo Martínez, A. Muñoz Ortega, V. Gómez Cabeza de Vaca, M. Gutiérrez Facial
Department of General Surgery and Gastroenterology.
Hospital Universitario Virgen del Rocío.
Sevilla
