Severe Blunt Liver Injury Complicated by Delayed Massive Hemobilia in a Toddler: A Case Report and Literature Review

Abstract

Introduction: Unintentional injuries remain a leading cause of disability among children. Although most of the pediatric patients suffering blunt liver injury can be successfully treated with non-operative therapy, the diagnosis and management of delayed life-threatening hemobilia following severe blunt liver injury, especially in the pediatric population, remain a challenge for clinicians.

Case presentation: A previously healthy 2-year-old girl suffered a severe blunt liver injury related to an electric bike, which was inadvertently activated by herself. She initially received non-operative therapy and was in a stable condition in the first 2 weeks. On the 16th and 22nd postinjury days, the patient presented with life-threatening massive hemobilia, which was confirmed via repeat emergent gastroscopy and hepatic arterial angiography. An emergency selective transarterial embolization of the involved branch of the left hepatic artery was successfully performed. The patient recovered uneventfully, and long-term follow-up was needed owing to a mild dilatation of the left intrahepatic bile duct.

Discussion: Incidental injury in children should be considered as a major public health issue and preventive measures should be taken to reduce its occurrence. Delayed massive hemobilia after severe blunt liver trauma is rare, and its accurate and timely diagnosis via emergency hepatic arterial angiography and selective angioembolization may allow prompt and optimal management to achieve good outcomes in the pediatric population.

Keywords: blunt hepatic trauma; case report; delayed massive hemobilia; injury prevention; toddler.

Figure 1

Plain CT scan (liver window A to C) showing irregular low-density lesions (pink circles) in SIVA and II, AAST Grade IV laceration and SVI, and AAST Grade III laceration.

Figure 2

Gastroduodenoscopy revealing active bleeding with fresh blood from the duodenal papilla (white triangle) (A). Hepatic arteriography showed contrast extravasation from the branch of the left hepatic artery (white arrow) (B) and selective transcatheter arterial embolization was successfully implemented (C, white arrow).

Figure 3

A recommended flowchart for the diagnosis and management of traumatic hemobilia in the pediatric population based on the literature and our preliminary experience.