Gunshot wound and shock bowel

Case contributed by Dr Jan Frank Gerstenmaier

Presentation

Shot in abdomen. Hypotensive.

Patient Data

Age: 22
Gender: Male
CT

CTA Thorax

NGT in situ. The oesophagus is dilated and filled with hyperdense fluid (HU ~ 50-70), likely reflecting aspiration. The right lower lobe is new completely collapsed.  No fractures of the ribs, sternum, clavicles and scapulae.

CT Abdomen and Pelvis

Recent midline laparotomy, the abdominal wall remains surgically open. Radiopaque material demonstrated in the left flank peritoneal cavity is consistent with surgical packs. Gas and fluid within the peritoneal cavity may be the result of recent surgery. 

There is evidence of active bleeding in the retroperitoneum encasing the abdominal aorta at the site of the renal artery offtake. There is likely associated injury to the renal arteries which may account for the patchy the renal perfusion. This may be solely accounted for however, by hypovolaemic shock given the extreme hypoperfusion of the remaining solid abdominal organs - adrenal and gallbladder hyperenhancement, hypoenhancement of the spleen compared to the liver. IVC is flattened. 

A definite site of bowel injury is not identified. However, multiple loops are small bowel show only patchy mural enhancement raising the possibility of bowel wall ischaemia.

There is a focal area of active bleed seen involving the antero-inferior aspect of the spleen with adjacent areas of active bleeding the in the adjacent anterior abdominal wall on the left extending inferiorly from the lower border of the spleen. No suspicious bony lesion.

Conclusion: 

Extensive retroperitoneal haematoma, with active bleed around the inferior abdominal aorta and both renal arteries, spleen and left lateral abdominal wall.

Case Discussion

The patient died shortly after the CT was performed.

This case demonstrates CT features of extreme hypovolaemic shock. 

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Case information

rID: 34892
Case created: 13th Mar 2015
Last edited: 13th Dec 2015
Inclusion in quiz mode: Included

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