Gunshot wound without entrance hole: where is the trick? - a case report and review of the literaturer.

Silvia Ministrini,Frida Pittiani,Nazario Portolani,Gianluca Baiocchi,Federico Gheza,Daniele Lomiento

doi:10.1186/s13017-015-0048-z

Silvia Ministrini, Frida Pittiani + Show 4 more

Open Access

https://doi.org/10.1186/s13017-015-0048-z

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Abstract

The presence at CT scan of more retained bullets than expected could be a very difficult interpretation challenge in the early management of gunshot wounds. The modern non operative management of haemodinamically stable patients without peritonitis requires that the trajectory of the bullet is clearly recognized. This clinical case reporting of a gunshot wound without evident entry hole, allows to discuss the diagnostic and therapeutic implications in the management of gunshot wounds cases with atypical entry and/or exit holes.

Highlights

In case of abdominal gunshot wound, exploratory surgery has always been deemed indicated, as the likelihood that the bullet has caused a perforation of the gastrointestinal tract is high; unlike the lesions of solid organs, characterized by haemoperitoneum detectable by Computed tomography (CT) scan, intestinal perforation may not be immediately recognized, especially when the CT is carried out quickly, so that the air contained in the bowel has not the time to go outside and to be recorded as an indirect sign of perforation
Full list of author information is available at the end of the article undetected entrance hole due to trans-anal gunshot, even if we found out 2 rare cases of unrecognized gastrointestinal bullet embolism [3,4,5]
We only find 2 rare cases of unrecognized bullet embolism in the gastrointestinal tract causing colonic perforation [3, 4]

Summary

Background

In case of abdominal gunshot wound, exploratory surgery has always been deemed indicated, as the likelihood that the bullet has caused a perforation of the gastrointestinal tract is high; unlike the lesions of solid organs, characterized by haemoperitoneum detectable by CT scan, intestinal perforation may not be immediately recognized, especially when the CT is carried out quickly, so that the air contained in the bowel has not the time to go outside and to be recorded as an indirect sign of perforation. The total body contrast-enhanced CT scan performed at the Emergency Department revealed a large subdural haematoma, a retained bullet in the brain (Fig. 1) and another retained projectile in the left lung (Fig. 2), without any evidence of thoracic wall wounds; there was no air outside the bowel (Fig. 3a) even if little air bubbles could be recognized near to the pubis (Fig. 3b) These findings were difficult to be interpreted, both by the radiologist, the surgeon and the anaesthesiologist, as patient’s examination performed in the shock room after the CT scan confirmed the only presence of a single bullet-hole located at the back of the neck. These findings were suspected for bowel perforation, the patient was translated into operative room: by laparotomy, the haemoperitoneum was drained

Discussion

Conclusion