Fulminant Liver Failure Associated with Abdominal Crush Injury in an Eleven-Year Old: A Case Report

An 11-year-old obese male was involved in an all-terrain vehicle rollover accident. He had elevated transaminase levels along with a lactic acidosis. The imaging studies did not reveal any major intra-abdominal or thoracic injuries. The physical exam was unremarkable. The patient had an unremarkable PICU course and was transferred to the floor the next day. Within 24 hours of his transfer, he was noted to have interval worsening in liver function tests. He developed fulminant liver failure (FLF), renal failure, and encephalopathy. An ultrasound of the liver revealed increased echogenicity in the right lobe with focal sparing. Patient was listed for transplant. Investigations into any underlying medical cause of FLF were negative. Liver failure was presumed to be related to ischemia/reperfusion injury of the liver. The renal failure was due to rhabdomyolysis and was supported with renal replacement therapy. Patient received supportive care for FLF and was noted to have significant recovery of liver and renal function with time. He was discharged home after a 3-week hospitalization. Patients with crush abdominal injuries and elevated transaminase levels without evidence of parenchymal liver disruption may need to be closely monitored for liver failure related to ischemia reperfusion. 1. Introduction Acute liver failure is characterized by the rapid development of severe liver injury with impaired synthetic function and hepatic encephalopathy in a patient without obvious, previous liver disease. Since the liver is capable of regeneration to a large extent, fulminant liver failure in principle may resolve with complete recovery. The decision for transplantation depends upon the likelihood of a spontaneous recovery. The indications for liver transplantation after trauma include uncontrolled hemorrhage, severe grade 4-5 injury resulting in liver parenchyma disruption, irreversible liver failure, and life-threatening postreperfusion injury. The requirement for liver transplantation after major liver trauma is rare with 19 cases reported in the literature with variable outcome [1]. FLF following abdominal trauma without hepatic parenchymal disruption has yet to be described in the pediatric population. In this case report, we describe an 11-year-old obese male with fulminant hepatic failure following a crush injury of the abdomen thought to be related to hepatic ischemia/reperfusion (I/R) injury. 2. Case Description An 11-year-old obese boy (weight 84 kilograms, height 1.52 meters with BMI of 36.17？kg/m2) was involved in an all-terrain vehicle (ATV) rollover