Conservative management of an abdominal gunshot injury with a peritoneal breach: wisdom or absurdity?

Abstract

SUMMARYSurgical exploration has been the standard of care for abdominal gunshot injuries. The authors report a case of a 28-year-old man who sustained a transabdominal gunshot injury, which entered the anterior abdominal wall and exited adjacent to the T12 vertebra posteriorly with a tangential trajectory. On presentation, the patient was haemodynamically stable with no peritoneal signs. Based on trajectory of the bullet, intra-abdominal injury was suspected. Therefore a CT scan abdomen with intravenous and rectal contrast was performed. The CT scan revealed no extravasation of the rectal contrast but showed free air specks behind the descending colon. Delayed renal images of the left ureter were also normal. Based on the clinical findings, the patient was managed nonoperatively with nothing per oral, intravenous antibiotics and frequent abdominal assessments. He made an uneventful recovery without necessitating laparotomy. BACKGROUND

Conservative Management of Gunshot Wound to Anterior Abdomen in a Resource-Poor Setting in the Caribbean

“…The NOM of blunt abdominal trauma and stab wounds to the abdomen is well recognized and accepted in haemodynamically stable patients [ 6 ]. The current standard of care for GSW to the abdomen is controversial, with exploratory laparotomy considered the standard previously.…”

“…Exploratory laparotomy for GSW to the abdomen was associated with a negative laparotomy rate of 20% and a complication rate of 20% in this group [ 7 ]. Non-therapeutic and negative laparotomies are linked with an increased hospital stay (5-9 days), cost [ 6 ] and morbidity (22%-41%) due to postop ileus, pneumonia, surgical site infections and thromboembolic events [ 8 ].…”

Filling Defect in Abdominal X-Ray Post Rectal Contrast Helps to Diagnose Descending Colon Perforation.

“…4 In a stable patient, CT scan is reliable for excluding significant injuries and plan the management. 8,9 Recently, the necessity of rectal contrast has been questioned. As demonstrated by our case, delayed abdominal films after rectal contrast revealed a filling defect at site of gunshot injury which raised suspicion of colon perforation despite the absence of clinical signs.…”