Collapsed Inferior Vena Cava (Arrow), With Bleeding Veins.

- Signs of inferior vena cava collapse: The inferior vena cava is considered collapsed if its anterior-posterior diameter below the renal vein level is less than ¼ of the transverse diameter and the change is not due to external compression [21].

Figure 1.13 : Collapsed inferior vena cava (arrow), with bleeding vessels.

Source: Shanmuganathan K, Mirvis SE [21].

1.5.3.3. Classification of liver damage on CT scan

Different injury classification systems have been proposed such as Moore's classification in 1979 and Mirvis's classification in 1989. In 1994, Moore and the American Association for the Surgery of Trauma (AAST) divided liver injuries into 6 grades [15]. This classification was updated in 2018, and is the system widely used in CTG. The updated table incorporates vascular injuries, which are imaging criteria for CTG [22].

Table 1.1 : CTG grading according to AAST 2018.

Team

Subcapsular hematoma <10% surface area or capsular tear, parenchymal depth <1cm.
Grade II	Subcapsular hematoma 10–50% of the surface area, intraparenchymal hematoma < 10cm in diameter or parenchymal tear 1-3cm deep, < 10cm long.
Grade III	Subcapsular hematoma > 50% surface area of subcapsular hematoma or parenchymal rupture, intraparenchymal hematoma > 10cm or extensive or parenchymal laceration > 3cm deep. Vascular injury with bleeding limited to liver parenchyma.
Grade IV	Tear and separation of 25 – 75% of the parenchyma in a liver lobe or 1-3 segments in a liver lobe (Couinaud). Damage to blood vessels, bleeding from the liver parenchyma into the peritoneal cavity.
Degree V	Parenchymal tear > 75% in 1 lobe of liver. Injury to the hepatic vein or inferior vena cava.

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Source: Morell-Hofert, D., Primavesi, F., Fodor, M. et al (2020) [22].

Figure 1.14 : CTG grade I. Parenchymal tear: fracture depth < 1cm (arrow).

Source: Shanmuganathan K, Mirvis SE [21].

Figure 1.15 : CTG grade II. Parenchymal tear 1-3 cm deep, < 10 cm long (arrow).

Figure 1.16 : Grade II CTG. Subcapsular hematoma of the liver 10–50% of the surface area.

Source: Shanmuganathan K, Mirvis SE [21].

Figure 1.17 . CTG grade III. Hematoma in the lower corner of the right liver lobe (arrow) > 10cm.

Figure 1.18 . CTG grade III. Liver parenchymal tear > 3cm in right liver lobe, bleeding.

Source: Shanmuganathan K, Mirvis SE [21].

Figure 1.19 . CTG grade IV. Parenchymal tear

> 50% right liver lobe.

Figure 1.20 . Grade IV CTG, multiple parenchymal tears in the T subsegment of the liver.

Source: Shanmuganathan K, Mirvis SE [21].

Figure 1.21 . CTG grade V. Tearing of liver parenchyma in right lobe and left lobe.

Figure 1.22 . Grade V liver injury. Deep liver laceration, damage to the hepatic veins.

Source: Shanmuganathan K, Mirvis SE [21].

According to some authors, the rate of CTG grade I is 1.2 - 35.8%; grade II is 18.1 - 27.3%; grade III is 21.6 - 44.0%; grade IV is 10.8 - 28.3%; grade V is 4.5 - 8.4% [2, 7, 34].

1.5.3.4 CTG complications:

Late bleeding : is the most common complication, occurring in 1.7% - 5.9% of conservatively treated CTG cases [8, 17]. CT scan shows a hematoma.

Figure 1.23 . Contrast-enhanced CT scan, multiple liver parenchymal lacerations and hematomas.

Figure 1.24 . Re-imaging shows a newly developed subcapsular hematoma due to late bleeding (arrow).

Source: Shanmuganathan K, Mirvis SE [21].

Liver or perihepatic abscess : Rate 0.6% to 4% [20, 28]. On pre- and post-contrast CT scans, the abscess is a fluid-dense mass, in

The core may contain air. The abscess wall absorbs contrast, the contour is reduced in density due to edema of the surrounding tissue.

Figure 1.25 . Liver abscess after CTG on CT scan (arrow).

Source: Shanmuganathan K, Mirvis SE [21].

Hepatic artery pseudoaneurysm : Hepatic artery aneurysm is caused by an artery that connects to the liver parenchyma and is surrounded by fibrous tissue. The reported incidence is about 1% [10]. CT scan before and after contrast injection shows that the lesion is a localized round lesion, strongly enhancing the contrast and occurring simultaneously with the aorta.

Figure 1.26 : Pseudoaneurysm of the hepatic artery (arrow).

(On CT scan/ Angiogram before embolization/ After treatment)

Source: Shanmuganathan K, Mirvis SE [21].

Biliary complications: On CT, increased free fluid in the peritoneal cavity and peritoneal enhancement and thickening suggest the diagnosis of biliary peritonitis [21].

Figure 1.27: Biliary peritonitis. Non-contrast CT scan obtained after 5 weeks (arrow).

Source: Shanmuganathan K, Mirvis SE [21].

1.5.4. Magnetic resonance

Magnetic resonance imaging is used in young patients or pregnant women with trauma where radiation safety concerns are raised by X-rays. It is indicated in cases of renal failure or allergy to contrast agents. Magnetic resonance cholangiopancreatography (MRCP) can be used to evaluate biliary tract injuries [28].

1.6. CTG treatment methods

1.6.1. Non-surgical conservative treatment

Most authors believe that conservative treatment is only possible for patients with stable hemodynamics; those admitted to the hospital in shock have a very high rate of emergency surgery.

Author Croce found a 73.5% success rate of preservation in hemodynamically stable patients after fluid resuscitation [29]. Complications were detected during follow-up.

1.6.2. Embolization treatment

In the late 1970s, endovascular intervention in CTG was considered a safe and effective treatment method in controlling bleeding.

postoperative bleeding, biliary bleeding and arteriovenous fistula, reducing the rate of complications and the amount of blood transfusion required [30].

1.6.3. Surgical treatment methods

1.6.3.1. Indications for surgery

Patients with severe hemorrhagic shock, shock that does not recover after intensive resuscitation, patients with CTG diagnosis requiring surgery or ineffective conservative treatment [31].

1.6.3.2. Preoperative resuscitation

Airway ventilation, respiratory support. Circulatory support: Ensure 2 intravenous lines. Place gastric tube, bladder urethral tube according to renal perfusion status and exclude urinary tract injury [28].

1.6.3.3. Intraoperative injury management

- Temporary hemostasis: Manual liver compression, Pringle maneuver, hemostatic gauze insertion, aortic clamping or subdiaphragmatic aortic occlusion

- Complete hemostasis: Electrocautery or suture hemostasis, selective hepatic artery ligation

- Liver transplant: Liver transplant is the last resort for irreparable liver damage.

CHAPTER 2: RESEARCH SUBJECTS AND METHODS

2.1. Research subjects

2.1.1. Subject

CTG patients regardless of age, gender, occupation and place of residence were diagnosed by CT scan at the Department of Imaging and treated at E Hospital from April 2021 to the end of January 2022 and at Viet Duc Friendship Hospital from December 2021 to March 2022.

2.1.2. Patient selection criteria

All CTG patients were diagnosed by CT scan at the Department of Imaging, Hospital E and at Viet Duc Friendship Hospital.

Full medical records are stored in the hospital's archives.

2.1.3. Exclusion criteria

Patients having CT scans at other medical facilities

Patients with pre-existing liver disease are a favorable factor for liver rupture. Severe multiple trauma cases affect hemodynamics.

2.2. Research location and time

The thesis was conducted at the Department of Surgery and the Department of Diagnostic Imaging of E Hospital and at the Department of Abdominal Emergency and the Department of Diagnostic Imaging of Viet Duc Friendship Hospital.

Time: from April 2021 to March 2022

2.3. Research method

2.3.1. Research design

The study was designed using a cross-sectional descriptive method.

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