ConditionInjuries & poisoning
Liver Injury (Liver Trauma)
A liver injury is damage to the liver from physical trauma, such as a car crash, fall, sports collision, stab or gunshot wound. The liver is the most commonly injured organ in abdominal trauma because it is large and sits under the lower right ribs. Injuries range from a small tear (laceration) or bruise to severe damage with life-threatening bleeding. Most stable patients are now treated without surgery, with close monitoring in hospital. Anyone with abdominal pain or signs of shock after a significant injury needs emergency care.
Also called: Hepatic trauma, liver laceration, liver trauma, hepatic injury, liver contusion
At a glance
- What it is
- Physical damage to the liver from blunt or penetrating trauma.
- Common causes
- Car crashes, falls, contact sports, assaults, stab and gunshot wounds.
- Signs
- Right upper belly pain, right shoulder pain, bruising, and signs of blood loss.
- Diagnosis
- FAST ultrasound and CT scan with contrast; graded I (minor) to V or VI (severe).
- Treatment
- Observation for stable patients; angiographic embolization or surgery for ongoing bleeding.
When to get help
Call 911 or go to the ER
- Abdominal pain, especially in the upper right, after a car crash, fall, sports collision or blow to the belly or lower ribs: call 911 or your local emergency number
- Dizziness, fainting, pale or clammy skin, rapid heartbeat or confusion after an injury (signs of internal bleeding)
- A stab or gunshot wound to the chest or abdomen
- Increasing belly swelling or pain in the days after a known liver injury
See a doctor within a day or two
- Right shoulder tip pain after abdominal trauma
- Fever, worsening pain, yellow skin or vomiting in the weeks after a liver injury (possible bile leak or abscess)
- A child with bruising on the abdomen from a seat belt or bicycle handlebar
Why the liver is vulnerable
The liver is the largest solid organ in the abdomen. It is soft, has a rich blood supply (receiving about a quarter of the heart's output), and is only partly protected by the lower ribs. Rapid deceleration in a crash, a direct blow, or rib fractures can tear it. A rib fracture on the lower right side should always raise suspicion of an underlying liver injury. Children's flexible ribs offer even less protection.
Causes
- blunt trauma: motor vehicle and motorcycle crashes, falls, sports collisions, bicycle handlebar injuries, assaults
- penetrating trauma: stab and gunshot wounds
- iatrogenic: complications of liver biopsy or surgery
- rarely, CPR chest compressions or difficult childbirth in newborns
Symptoms
- pain in the upper right abdomen, sometimes spreading across the belly
- pain in the right shoulder tip, from blood irritating the diaphragm
- tenderness and bruising over the right lower ribs or abdomen
- abdominal swelling
- signs of blood loss: dizziness, weakness, a rapid pulse, low blood pressure, pale clammy skin, confusion
Symptoms may be masked by other injuries, alcohol, drugs or head injury, so trauma teams look for liver injury systematically.
How liver injuries are graded
The American Association for the Surgery of Trauma (AAST) grades liver injuries by size and depth:
| Grade | Description |
|---|---|
| I | Small hematoma under the capsule (under 10% of surface) or tear under 1 cm deep |
| II | Larger hematoma (10% to 50% of surface) or tear 1 to 3 cm deep |
| III | Hematoma over 50% of surface or tear over 3 cm deep; active bleeding contained in the liver |
| IV | Disruption of 25% to 75% of a liver lobe; active bleeding into the abdomen |
| V | Disruption of over 75% of a lobe, or injury to major veins near the liver |
Grade guides treatment, but how stable the patient is matters most.
Diagnosis
- primary trauma assessment following ATLS principles
- FAST ultrasound (Focused Assessment with Sonography for Trauma): a rapid bedside scan for free blood in the abdomen
- CT scan with IV contrast in stable patients: shows the injury's extent, active bleeding and other injuries
- blood tests: hemoglobin, liver enzymes, clotting, blood type
- in unstable patients, the decision for surgery may be made without CT
Treatment
Non-operative management
Most blunt liver injuries in stable patients, including many high-grade injuries, are treated without surgery:
- hospital admission with close monitoring of vital signs and blood counts
- bed rest initially
- blood transfusion if needed
- repeat imaging if symptoms change
Success rates are high in properly selected patients.
Angioembolization
If CT shows active bleeding but the patient is stable, an interventional radiologist can block the bleeding vessel through a catheter, avoiding open surgery.
Surgery
Emergency surgery is needed for patients who are unstable from bleeding, or who have other injuries requiring operation (such as bowel injury). Techniques include packing the liver to control bleeding, repairing tears, removing damaged tissue and "damage control" surgery with a planned return to the operating room. Many penetrating injuries require surgery.
Complications
- delayed bleeding
- bile leak (biloma), or bile in the abdomen causing peritonitis
- liver abscess
- hemobilia (bleeding into the bile ducts)
- liver failure, rarely, with very severe injury
- complications from associated injuries, such as spleen injury or rib fractures
Recovery
Most liver injuries heal completely, because the liver has a remarkable capacity to repair itself. After hospital discharge:
- avoid contact sports, heavy lifting and strenuous activity for a period based on injury grade, commonly about 6 to 12 weeks or as advised by the trauma team
- return immediately if pain worsens, fever develops, or you feel faint
- follow-up imaging is not always needed unless symptoms recur
Frequently asked questions
What are the symptoms of a liver injury?
Symptoms include pain in the upper right abdomen, right shoulder pain, tenderness over the lower right ribs and abdominal swelling. Signs of internal bleeding, such as dizziness, a fast pulse, pale skin and fainting, mean an emergency.
How long does a lacerated liver take to heal?
Minor lacerations often heal within several weeks, and more severe injuries over a few months. Most people are advised to avoid contact sports and heavy activity for about 6 to 12 weeks, depending on the grade.
Do all liver injuries need surgery?
No. Most blunt liver injuries in stable patients heal with observation in hospital. Surgery or catheter embolization is needed when bleeding continues, the patient is unstable, or there are other abdominal injuries.
Can the liver repair itself after injury?
Yes. The liver can regenerate and usually heals completely after trauma. Even when part of the liver is removed, the remaining tissue can grow back to near-normal size over months.
Sources
This guide was written from current patient and clinical guidance, including:
- American Association for the Surgery of Trauma (AAST): Organ Injury Scaling: Liver
- World Society of Emergency Surgery (WSES): Liver trauma guidelines
- Eastern Association for the Surgery of Trauma (EAST): Nonoperative management of blunt hepatic injury guideline
- American College of Surgeons: Advanced Trauma Life Support (ATLS)
- MedlinePlus: Abdominal trauma