| Objective The aim of the study is to explore the value of contrast-enhanced ultrasound (CEUS) in diagnosis the blunt hepatic trauma and the appliance of hemostatic agents injected directly into injury site under the guidance of CEUS.Methods (1) Blunt hepatic injuries were made in 30 dogs. Baseline ultrasound, CEUS and CECT were used to detect traumatic lesions of livers after impacting. According to the AAST scale, the degree of injuries was determined by CEUS, the results of which were compared with those of CECT. (2) Laboratory was performed on 14 dogs. A wound of grade IV on a hepatic lobe was created. All wounded animals were randomly divided into two groups, the treatment group and the control group. In the treatment group, hemocoagulase 2mL combined withα-cyanoacrylate 1mL were injected directly into the liver injury site under the guidance of CEUS, and saline 3mLwas injected into the dogs of the control group. The bleeding time (BT) and total blood loss were recorded for 30 min after injection. The adherence to the liver wound was recorded. Gross and histologic specimens were harvested for pathology after the animals were sacrificed. (3) twenty-one dogs were divided into four groups according to the injury severity decided by CEUS: group 1: the injury was grade I-III, no active bleeding and underwent conservative therapy; group 2: the injury was grade III-IV and underwent conservative therapy; group 3: the injury was grade III-IV and underwent CEUS-guided injective therapy; group 4: the injury was over grade IV and underwent operative management. (4) 68 patients with proved blunt hepatic injuries underwent contrast-enhanced ultrasound (CEUS) before treatment. Operation was performed in 30 cases and CT examination in 48 cases. All injuries were classified with a five-point CEUS-based grading system. The CEUS injury grades were compared with CT, surgical finding and the follow-up results. (5) 11 patients with hepatic trauma of grade III-IV were consecutively enrolled in this study. Percutaneous injection of hemocoagulase andα-cyanoacrylate was performed by CEUS-guidance in all patients. Vital signs, hemoglobin (Hb) and the volume of hematocelia were recorded. Ultrasound examination was performed at 1,3,7 and 14 days and 1, 6 months after treatment.Results (1) 30 injuries were created successfully. The injuries showed as irregular non-enhancement in CEUS. Active bleeding showed as hyperechoic strip or nodosity in 17 injuries. The sensitivity of CEUS in diagnosis hepatic injury is 100%, superior to baseline ultrasound 36.7% (P= 0.000). The coincidence with CEUS in hepatic injury was 93.3% compared with CECT. (2) BT in the treatment group was 5.8±0.15s. The control group presented still bleeding after 30min. The blood loss of treatment group was (12.3±4.5)mL, less than that of control group (85.8±7.5)mL(P< 0.01). The transfusion volume in the treatment and control group was (66±12) mL vs (180±23)mL respectively(P < 0. 01). Pathologic examination revealed that the injury site treated was covered with clot and glue membrane, and no hematoma was observed. Histopathologic examination showed hemostitic glue in vessels and inflammatory cell infiltration between hepatocytes. Micro-vesselswere embolized by hemostitic glue. In the control, there was a little blood clot in gross samples, the wound was split and histopathology demonstrated local bleeding and inflammatory cell infiltration. (3) For five injuries of group 1 were cured throughout conservative therapy. Two injuries died and three ones were cured in group 2. Six injuries of group 3 were all cured throughout CEUS-guided injective therapy. Two injuries died and three ones were cured throughout surgery in group 4. (4) The coincidence rate of the CEUS liver injury grading compared with operative results was 93.3% (28/30), which had good grading concordance (P=0.000). The accuracy rate of CEUS and CT grades was 91.7% (44/48), which had good grading concordance (P=0.000). (5) Immediately after CEUS-guided hemostatic injections, active bleeding from the injury sites disappeared and follow-up CEUS showed local hyper- echogenicity at the injection site. The 1- and 2-week and 1-month follow-ups confirmed that the hyperechogenicity at the absorbable cyanoacrylate injection site was attenuated, and the size of injury lesion was gradually reduced. The 6-month follow-up CEUS indicated that the lesion had recovered and perfusion of spleen was uniform. Free intraperitoneal liquid volume was gradually reduced. From 30 minutes after injection arterial blood pressure began to ascend (P<0.05), heart rate became slower than before the treatment (P<0.05). Hb gradually increased to the normal level.Conclusions CEUS can reflect degree of injury accurately and have good concordance with CECT and pathology; CEUS can provide reliable help for selecting therapy mode of blunt hepatic trauma; CEUS-guided hemostatic agents injection therapy for hepatic truama is effective, safe and no adverse effect, which carry out the minimal invasive treatment of hepatic trauma.
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