Low-Energy Trauma: Severe Liver Injury in an Elderly Patient from a Seated Fall

Introduction

Falls can lead to trauma and death, with older adults having a higher risk of falling than younger individuals [1]. The annual incidence of falls among older adults dwelling in community environments was reported to be 32%, of which 24% were associated with severe injuries and 6% with fractures [2]. Moreover, fatalities resulting from low-energy trauma have been attributed to falls [3]. Therefore, primary care physicians must promptly identify fractures and organ injuries when assessing patients who have experienced falls and manage them appropriately to reduce damage and prevent the risk of death.

Case Report

A woman in her 80s, who was living independently, had been taking triazolam 0.25 mg and ramelteon 8 mg daily for 4 years. She was not on anticoagulant or antiplatelet medications and had no history of alcohol consumption or hepatitis B or C. At midday on day 1, she fell from a chair while napping and bruised the right side of her body either due to hitting the chair or the floor. She monitored her condition by herself at home without seeking medical attention. Following the fall, she experienced nausea, vomiting, loose stools 4–5 times daily, and right-sided abdominal pain. On day 2, she visited our clinic in the morning due to persistent nausea and vomiting. She could walk independently, although she looked pale. Her body temperature was 36.8°C, blood pressure 100/48 mmHg, and pulse rate 76 beats/minute. Mild conjunctival pallor was noted. She had normal chest auscultation, ecchymoses and tenderness on the right side of her chest, no joint restrictions in her extremities, normal bowel sounds, a flat and soft abdomen, and tenderness in her general lower abdomen without signs of peritoneal irritation. A rib fracture was suspected in the absence of X-ray imaging, and she was diagnosed with acute gastroenteritis. Intravenous fluid infusion and oral loxoprofen sodium 60 mg were administered after blood sampling. She was discharged home with a prescription for oral metoclopramide 15 mg, Clostridium butyricum (probiotics) 60 mg, to be administered in 3 divided doses daily, a ketoprofen patch 40 mg, and oral loxoprofen sodium 60 mg, to be used as needed.

The blood test results, which the physician was notified of on the evening of day 2, are shown in Table 1. Over the phone, the patient reported improvement in symptoms, such as loose stools, nausea, vomiting, and right chest pain, and stated that she felt well overall. Consequently, she was referred to the hospital for a follow-up visit on day 3.

Upon arrival at the tertiary hospital, the patient’s vital signs were as follows: body temperature 37.6°C, Glasgow Coma Scale score 15, blood pressure 126/53 mmHg, pulse rate 105 beats/ minute, respiratory rate 25 breaths/minute, and oxygen saturation 96% (room air). Spontaneous pain and a subcutaneous hematoma were observed in the right chest on the flank area. The laboratory data are shown in Table 1.

A chest X-ray image revealed subcutaneous emphysema in her right chest area (Figure 1). Furthermore, computed tomography (CT) of her chest and abdomen with enhancement showed a liver laceration in the posterior segment of the right hepatic lobe, accompanied by a perilesional hematoma. The collective findings resulted in the diagnosis of severe traumatic liver injury, categorized as grade III according to the American Association for the Surgery of Trauma-Organ Injury Scale (Figure 2A) [4]. Additionally, a traumatic hemothorax was identified on her right side, along with fractures of the 7th–11th ribs on the right side (Figure 2B).

Because there was no extravasation of contrast agent into the extravascular space, vascular embolization or surgery was not performed. On day 8, the patient presented with a right-sided pleural effusion, which was drained by thoracentesis. Abdominal CT on day 10 revealed no enlargement of the hemorrhage within or around the liver. The patient’s ability to perform activities of daily living gradually improved; therefore, she was discharged home on day 12.

Discussion

The present case represents a rare cause of traumatic liver injury in an older woman with gastrointestinal symptoms following low-energy trauma. Herein, we discuss critical points for suspecting organ injury in patients with falls, examine the factors that contributed to delayed diagnosis in this patient, and explore the association between falls and gastrointestinal symptoms. The patient, being elderly and taking concomitant hypnotics, was at risk of falling.

The first key point is to suspect organ injury in a patient who fell, considering the potential for fatal outcomes from low-energy trauma. The annual rate of fall-related fatalities has been reported to be 0.66% among Chinese residents aged ≥80 years [5], and falls account for 36% of accidental deaths among Japanese residents aged ≥80 years [6]. Autopsies of patients with trauma-related deaths have included those caused by falls from heights less than 1 m, and the most common cause of fatalities resulting from low-energy trauma is falls [3]. According to the American Association for the Surgery of Trauma-Organ Injury Scale, our patient experienced a grade III liver injury, which has an associated 4–15% mortality rate, 81% necessity of surgery, and 18% need for transfusion [7,8]. The second key point is recognizing the risk factors for fall-related fatalities and severe organ damage. Among the patients with rib fractures due to low-energy trauma, those with factors such as older age, male sex, falls, and a high number of rib fractures had higher mortality [9], and fractures of the 5th–8th ribs were associated with liver injury [10]. In the present case, factors other than sex all contributed to the risk of fatality and organ injury, indicating a relatively high mortality risk was associated with the low-energy trauma at the initial assessment. Second to considering organ injury as a differential diagnosis, performing a focused assessment with sonography in trauma (FAST) examination is vital. FAST has a high specificity for diagnosing intraperitoneal bleeding, ranging from 92–100%, although its sensitivity is low, at 38–88% [11,12]. Therefore, primary care physicians should enhance their knowledge and skills regarding FAST and carefully monitor the progress of patients and perform blood tests when FAST yields negative findings. Few cases of liver injuries resulting from low-energy trauma have been reported [7], and no reports of liver injuries caused by falls from a seated position exist in the medical literature. We report this case to alert physicians that falls from low heights have the potential for severe outcomes, including organ injury and death.

In this patient, the delayed diagnosis of liver injury could be attributed to several cognitive biases, including availability bias, where the diagnosis gravitated towards the common concerns of vomiting and loose stools; confirmation bias, where uncommon findings associated with simple falls and fractures were disregarded, such as digestive concerns and pallor; and early closure bias, where the physician prematurely dismissed the possibility of organ injury due to low-energy trauma [13]. Consistent with the present case, the 3 cognitive biases have, on average, been reported to contribute to a single diagnostic error [14]. Moreover, the early diagnosis of non-hemorrhagic gastrointestinal disorders, most of which have been acute gastroenteritis, is challenging, with a high potential for medical litigation [15]. The present patient had vomiting and loose stools, which is atypical of a course following chest and abdominal trauma, as well as non-specific symptoms. Since the frequency of abdominal organ injuries in patients who fell, including falls from heights, has been as low as 4% [16], that in patients with only low-energy trauma is estimated to be even lower. Therefore, diagnosing liver injury following a fall from a seated position is uncommon; however, we hope that sharing this case will help reduce cognitive bias that may lead physicians to overlook organ injuries and ultimately contribute to reducing diagnostic errors in primary care.

Regarding the cause of gastrointestinal symptoms, mesenteric venous thrombosis was not detected in the contrast-enhanced abdominal CT of this patient. Notably, mesenteric venous thrombosis has been reported to present with nausea, vomiting, and diarrhea following abdominal trauma [17]. While falls can cause ischemic hepatitis [18], and both ischemic hepatitis and simple liver injury can lead to nausea and vomiting [19,20], diarrhea is an uncommon symptom for both. Therefore, we considered the possibility of ischemic enteritis complicated by liver injury or ischemic hepatitis as a cause of the gastrointestinal symptoms in this patient. Although shock could not be definitively diagnosed, the patient’s systolic blood pressure on day 2 was 26 mmHg lower than that on day 3, her hemoglobin level was low on day 3, the posterior segment of her right hepatic lobe was observed to have ruptured on CT, and the size of the fissured area that involved a hematoma was large, which suggested a substantial amount of bleeding at the time of injury. Insufficient circulation volume or oxygen to the liver or systemic circulation due to liver injury would have led to ischemic hepatitis and ischemic enteritis. Since the patient’s gastrointestinal symptoms had improved on day 3 and edema of the bowel wall was not detected on CT on day 3, ischemic hepatitis and ischemic enteritis would be temporal changes, if present. Although the cause of the loose stools in this patient is unclear, considering the patient’s gastrointestinal symptoms holistically, the symptoms that remain unexplained by simple contusions or fractures following a fall could be a phenotype of organ injury and important diagnostic clues.

Conclusions

The present case shows that low-energy trauma, such as a fall from a seated position, can result in severe traumatic liver injury. Physicians should suspect organ injury after low-energy trauma and know the factors that increase the risk of death and organ injury. Notably, gastroenteritis is a typical misdiagnosis, and a patient’s atypical clinical course and non-specific symptoms after trauma can be associated with organ injury.