Liver Infarct Management

Diagnosis and Imaging

• CT scan with intravenous contrast is the gold standard for diagnosis of liver infarct in hemodynamically stable patients 1

Treatment and Management

• For hemodynamically unstable patients, consider operative management if instability persists 1, 2
• Non-operative management (NOM) should be the treatment of choice for all hemodynamically stable patients 1
• Serial clinical evaluations (physical exams and laboratory testing) must be performed to detect changes in clinical status 1, 3, 4
• Delayed hemorrhage without severe hemodynamic compromise may be managed with angiography/angioembolization (AG/AE) 1
• Hepatic artery pseudoaneurysm should be managed with AG/AE to prevent rupture 1
• Intrahepatic abscesses may be successfully treated with percutaneous drainage 1
• Symptomatic or infected bilomas should be managed with percutaneous drainage 1
• Combination of percutaneous drainage and endoscopic techniques may be considered for post-traumatic biliary complications 1
• Laparoscopic lavage/drainage and endoscopic stenting may be considered for delayed post-traumatic biliary fistula 1
• Fluid resuscitation with balanced crystalloids and/or albumin should be initiated, followed by vasopressor support if needed, with norepinephrine as the first-line vasopressor, and a target mean arterial pressure (MAP) of 65 mmHg, as recommended by the American Association for the Study of Liver Diseases 5, 4
• Norepinephrine (0.01–0.5 μg/kg/min) should be initiated as the first-line vasopressor when fluid resuscitation fails to maintain adequate blood pressure, with vasopressin as a potential second-line agent, as recommended by the American Association for the Study of Liver Diseases 5
• Screening for adrenal insufficiency or empiric trial of hydrocortisone (50 mg IV every 6 hours or 200-mg continuous infusion) should be considered for refractory shock requiring high-dose vasopressors, with a duration of 7 days or until ICU discharge, as recommended by the American College of Critical Care Medicine 3, 4, 5

Prevention and Prophylaxis

• Mechanical prophylaxis is safe and should be considered in all patients without absolute contraindication 1
• LMWH-based prophylaxis should be started as soon as possible when the patient is stabilized 1
• Individualization of the risk-benefit balance of anticoagulant reversal is necessary in patients taking anticoagulants 1, 3
• The World Journal of Emergency Surgery guidelines suggest individualizing anticoagulant reversal based on risk-benefit assessment 1

Rehabilitation and Follow-up

• Early mobilization should be achieved in stable patients 1
• In the absence of contraindications, enteral feeding should be started as soon as possible 1
• Mandatory late follow-up imaging is not indicated and should be used only if clinical condition or symptoms suggest a complication 1
• Most liver lesions heal in approximately 4 months 1, 2
• Normal physical activities may be resumed after 3-4 months following moderate to severe liver injuries 1
• If CT scan follow-up shows significant healing, normal activity can be resumed even after 1 month 2

Patient Education

• Patients should be advised to not remain alone for long periods and return immediately to the hospital if experiencing increasing abdominal pain, lightheadedness, nausea, or vomiting 1, 2

Surgical Intervention

• In cases of large devitalized liver portions, delayed hepatic resection may be considered, but only in centers with necessary expertise 2
• Operative management is indicated for unstable patients with primary goals to control hemorrhage and bile leak, while non-operative management is preferred for hemodynamically stable patients 1, 3, 4
• The American Association for the Study of Liver Diseases recommends maintaining continuous glucose monitoring and infusion as hypoglycemia is common and symptoms may be obscured by encephalopathy, and correcting electrolyte abnormalities, particularly phosphate, magnesium, and potassium, which frequently require repeated supplementation 4
• The American Association for the Study of Liver Diseases suggests considering renal dysfunction and using continuous renal replacement therapy rather than intermittent hemodialysis if needed, and initiating early enteral feeding (approximately 60 grams of protein per day is reasonable) unless contraindicated 4

Monitoring and Management Strategies

3, 1