A 23-year-old-man is brought to the emergency department after he was stabbed in the right upper quadrant of the abdomen. His blood pressure is 70/42 mm Hg, pulse is 135/min, and respirations are 26/min; pulse oximetry shows oxygen saturation of 95% on room air. Physical examination shows a stab wound 2 cm inferior to the right costal margin. The patient's abdomen is firm and distended. Focused assessment with sonography for trauma (FAST) is positive for blood in the right upper quadrant. He is taken for immediate laparotomy, and approximately 1 liter of blood is evacuated from the peritoneal cavity. Brisk, nonpulsatile bleeding is seen emanating from behind the liver. The surgeon occludes the hepatoduodenal ligament, but the patient continues to hemorrhage. Which of the following structures is the most likely source of this patient's bleeding?

Question

A 23-year-old-man is brought to the emergency department after he was stabbed in the right upper quadrant of the abdomen.  His blood pressure is 70/42 mm Hg, pulse is 135/min, and respirations are 26/min; pulse oximetry shows oxygen saturation of 95% on room air.  Physical examination shows a stab wound 2 cm inferior to the right costal margin.  The patient's abdomen is firm and distended.  Focused assessment with sonography for trauma (FAST) is positive for blood in the right upper quadrant.  He is taken for immediate laparotomy, and approximately 1 liter of blood is evacuated from the peritoneal cavity.  Brisk, nonpulsatile bleeding is seen emanating from behind the liver.  The surgeon occludes the hepatoduodenal ligament, but the patient continues to hemorrhage.  Which of the following structures is the most likely source of this patient's bleeding?

Quizplus · Accepted Answer

11ec160b_3587_17e7_9249_c5eb0ce9c612_MD0001_00 The portal triad runs through the hepatoduodenal ligament and is composed of the hepatic artery, portal vein, and common bile duct. In the setting of traumatic liver injury with persistent bleeding, occlusion of the hepatoduodenal ligament can be performed to identify the vascular source (ie, the Pringle maneuver). If liver bleeding does not cease when the portal triad is occluded, it is likely that there has been injury to the inferior vena cava or hepatic veins. Although the inferior vena cava is a retroperitoneal structure, penetrating trauma can disrupt tissue barriers, facilitating bleeding into the peritoneal compartment. (Choice A) The common bile duct makes up one-third of the portal triad. Damage to the biliary ducts can cause biliary leakage and bile peritonitis. (Choice B) The cystic artery most commonly arises from the right hepatic artery and would be devascularized following portal triad occlusion. In addition, arterial bleeding is usually pulsatile whereas venous bleeding is nonpulsatile. (Choices C and E) The hepatic artery and portal vein are part of the portal triad; occlusion of the hepatoduodenal ligament would cause the bleeding to stop if either of these vessels is the source. Educational objective: Occlusion of the portal triad can be used to distinguish the source of right upper quadrant bleeding. If the bleeding subsides following occlusion, the source is likely to be the hepatic artery or portal vein. If hepatic bleeding persists after occlusion, the inferior vena cava or hepatic veins are likely to be injured. __________ References: Vascular control during hepatectomy: review of methods and results. (http://www.ncbi.nlm.nih.gov/pubmed/16222453) Emergency strategies and trends in the management of liver trauma. (http://www.ncbi.nlm.nih.gov/pubmed/22673827)

A 23-Year-Old-Man Is Brought to the Emergency Department After He