Liver cirrhosis: An unfavorable factor for nonoperative management of blunt splenic injury

Jen Feng Fang, Ray Jade Chen, Being Chuan Lin, Yu Bau Hsu, Jung Liang Kao, Miin Fu Chen

Research output: Contribution to journalArticle

29 Citations (Scopus)

Abstract

Background: Nonoperative management (NOM) of blunt splenic injury (BSI) is currently a well-accepted treatment modality for hemodynamically stable patients. More than 60% of BSI patients can be successfully treated without operation. Old age, high-grade injury, contrast blush, and multiple associated injuries were reported to have a higher failure rate but not to be exclusive of NOM. The purpose of this study was to review the treatment courses and results of a special group of BSI patients with coexistent liver cirrhosis. Factors leading to poor results were analyzed and treatment strategy was proposed accordingly. Methods: During a 5-year period, 487 patients With BSI were treated following a standard protocol. Twelve of them had underlying liver cirrhosis. The medical records, radiographic findings, laboratory data, and operative variables were retrospectively reviewed. Results: Eighty-nine (18%) patients had immediate celiotomy for splenic hemorrhage with unstable hemodynamic status, 59 (12%) had non - spleen-related or nontherapeutic laparotomy, and 339 (70%) patients received NOM initially. Failure of NOM was found in 74 patients (22%). Twelve patients with initial NOM had coexistent liver cirrhosis. The amount of blood transfusion within 72 hours after admission for these 12 patients ranged from 4 to 26 units. Patients with coexistent liver cirrhosis and BSI had a significantly higher NOM failure rate (92% vs. 19%). In NOM failure patients, those with liver cirrhosis had lower Injury Severity Scores, lower splenic injury severity grades, more blood transfusions, and a higher mortality rate. Risk factors for mortality in these patients included a higher Injury Severity Score, a severely elevated prothrombin time (PT), a larger transfusion requirement, and a lower serum albumin level. Conclusion: Liver cirrhosis with subsequent development of portal hypertension, splenomegaly, and coagulopathy makes spontaneous hemostasis of the injured spleen difficult. NOM for BSI patients with coexistent liver cirrhosis carries a high failure and mortality rate. NOM may be successful in only a small group of patients with low-grade single-organ injury and with a normal or mildly elevated PT. Aggressive correction of coagulopathy should be performed in these patients. High-grade splenic injury, multiple associated injuries, and an elevated PT are indicators for early surgery. The mortality rate is high in patients with a severely prolonged PT irrespective of treatment modalities.

Original languageEnglish
Pages (from-to)1131-1136
Number of pages6
JournalJournal of Trauma - Injury, Infection and Critical Care
Volume54
Issue number6
Publication statusPublished - Jun 1 2003
Externally publishedYes

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Nonpenetrating Wounds
Liver Cirrhosis
Prothrombin Time
Injury Severity Score
Mortality
Multiple Trauma
Wounds and Injuries
Blood Transfusion
Spleen
Patient Admission
Splenomegaly
Portal Hypertension
Therapeutics
Hemostasis
Serum Albumin
Laparotomy

Keywords

  • Blunt splenic injury (BSI)
  • Liver cirrhosis
  • Nonoperative management (NOM)
  • Prothrombin time (PT)

ASJC Scopus subject areas

  • Surgery

Cite this

Liver cirrhosis : An unfavorable factor for nonoperative management of blunt splenic injury. / Fang, Jen Feng; Chen, Ray Jade; Lin, Being Chuan; Hsu, Yu Bau; Kao, Jung Liang; Chen, Miin Fu.

In: Journal of Trauma - Injury, Infection and Critical Care, Vol. 54, No. 6, 01.06.2003, p. 1131-1136.

Research output: Contribution to journalArticle

Fang, Jen Feng ; Chen, Ray Jade ; Lin, Being Chuan ; Hsu, Yu Bau ; Kao, Jung Liang ; Chen, Miin Fu. / Liver cirrhosis : An unfavorable factor for nonoperative management of blunt splenic injury. In: Journal of Trauma - Injury, Infection and Critical Care. 2003 ; Vol. 54, No. 6. pp. 1131-1136.
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abstract = "Background: Nonoperative management (NOM) of blunt splenic injury (BSI) is currently a well-accepted treatment modality for hemodynamically stable patients. More than 60{\%} of BSI patients can be successfully treated without operation. Old age, high-grade injury, contrast blush, and multiple associated injuries were reported to have a higher failure rate but not to be exclusive of NOM. The purpose of this study was to review the treatment courses and results of a special group of BSI patients with coexistent liver cirrhosis. Factors leading to poor results were analyzed and treatment strategy was proposed accordingly. Methods: During a 5-year period, 487 patients With BSI were treated following a standard protocol. Twelve of them had underlying liver cirrhosis. The medical records, radiographic findings, laboratory data, and operative variables were retrospectively reviewed. Results: Eighty-nine (18{\%}) patients had immediate celiotomy for splenic hemorrhage with unstable hemodynamic status, 59 (12{\%}) had non - spleen-related or nontherapeutic laparotomy, and 339 (70{\%}) patients received NOM initially. Failure of NOM was found in 74 patients (22{\%}). Twelve patients with initial NOM had coexistent liver cirrhosis. The amount of blood transfusion within 72 hours after admission for these 12 patients ranged from 4 to 26 units. Patients with coexistent liver cirrhosis and BSI had a significantly higher NOM failure rate (92{\%} vs. 19{\%}). In NOM failure patients, those with liver cirrhosis had lower Injury Severity Scores, lower splenic injury severity grades, more blood transfusions, and a higher mortality rate. Risk factors for mortality in these patients included a higher Injury Severity Score, a severely elevated prothrombin time (PT), a larger transfusion requirement, and a lower serum albumin level. Conclusion: Liver cirrhosis with subsequent development of portal hypertension, splenomegaly, and coagulopathy makes spontaneous hemostasis of the injured spleen difficult. NOM for BSI patients with coexistent liver cirrhosis carries a high failure and mortality rate. NOM may be successful in only a small group of patients with low-grade single-organ injury and with a normal or mildly elevated PT. Aggressive correction of coagulopathy should be performed in these patients. High-grade splenic injury, multiple associated injuries, and an elevated PT are indicators for early surgery. The mortality rate is high in patients with a severely prolonged PT irrespective of treatment modalities.",
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AU - Kao, Jung Liang

AU - Chen, Miin Fu

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N2 - Background: Nonoperative management (NOM) of blunt splenic injury (BSI) is currently a well-accepted treatment modality for hemodynamically stable patients. More than 60% of BSI patients can be successfully treated without operation. Old age, high-grade injury, contrast blush, and multiple associated injuries were reported to have a higher failure rate but not to be exclusive of NOM. The purpose of this study was to review the treatment courses and results of a special group of BSI patients with coexistent liver cirrhosis. Factors leading to poor results were analyzed and treatment strategy was proposed accordingly. Methods: During a 5-year period, 487 patients With BSI were treated following a standard protocol. Twelve of them had underlying liver cirrhosis. The medical records, radiographic findings, laboratory data, and operative variables were retrospectively reviewed. Results: Eighty-nine (18%) patients had immediate celiotomy for splenic hemorrhage with unstable hemodynamic status, 59 (12%) had non - spleen-related or nontherapeutic laparotomy, and 339 (70%) patients received NOM initially. Failure of NOM was found in 74 patients (22%). Twelve patients with initial NOM had coexistent liver cirrhosis. The amount of blood transfusion within 72 hours after admission for these 12 patients ranged from 4 to 26 units. Patients with coexistent liver cirrhosis and BSI had a significantly higher NOM failure rate (92% vs. 19%). In NOM failure patients, those with liver cirrhosis had lower Injury Severity Scores, lower splenic injury severity grades, more blood transfusions, and a higher mortality rate. Risk factors for mortality in these patients included a higher Injury Severity Score, a severely elevated prothrombin time (PT), a larger transfusion requirement, and a lower serum albumin level. Conclusion: Liver cirrhosis with subsequent development of portal hypertension, splenomegaly, and coagulopathy makes spontaneous hemostasis of the injured spleen difficult. NOM for BSI patients with coexistent liver cirrhosis carries a high failure and mortality rate. NOM may be successful in only a small group of patients with low-grade single-organ injury and with a normal or mildly elevated PT. Aggressive correction of coagulopathy should be performed in these patients. High-grade splenic injury, multiple associated injuries, and an elevated PT are indicators for early surgery. The mortality rate is high in patients with a severely prolonged PT irrespective of treatment modalities.

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KW - Liver cirrhosis

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KW - Prothrombin time (PT)

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