Delayed hemorrhage after nonoperative management of blunt hepatic trauma in children: A rare but significant event

Purpose: Nonoperative management of blunt hepatic injury (BHI) has became w idely accepted in hemodynamically stable children without ongoing transfusi on requirements. However, late hemorrhage, especially after discharge from the hospital can be devastating. The authors report the occurrence of serio us late hemorrhage and the sentinel signs and symptoms in children at risk for this complication. Methods: Nonoperative management of hemodynamically stable children include d computed tomography (CT) evaluation on admission and hospitalization with bed rest for 7 days, regardless of injury grade. Activity was restricted f or 3 months after discharge. Hepatic injuries were classified according to grade, amount of hemoperitoneum, and periportal hypoattenuation. Results: Over 5 years, nonoperative management was successful in 74 of 75 c hildren. One child returned to the hospital 3 days after discharge with rec urrent hemorrhage necessitating surgical control. Review of the CT findings demonstrated that he was the only child with severe liver injury in all fo ur classifications. A second child, initially treated at an outside hospita l, presented 10 days after injury with ongoing bleeding and died despite su rgical intervention. Only the two children with delayed bleeding had persis tent right abdominal and shoulder discomfort in the week after BHI. Conclusions: Our findings support nonoperative management of BHI. However, late hemorrhage heralded by persistence of right abdominal and shoulder pai n may occur in children with severe hepatic trauma and high injury severity scores in multiple classifications. J Pediatr Surg 33.;60-64. Copyright (C ) 1999 by W.B. Saunders Company.