Liver laceration from gunshot in a thalassemia intermedia patient

Case contributed by Dr Yair Glick

Presentation

Gunshot wound to abdomen.

Patient Data

Age: 25 years
Gender: Male

Well-placed ETT and NGT. Urinary bladder catheterised and partially voided.

No evidence of fracture, pneumothorax/pneumomediastinum, or lung contusion.

Bullet has entered via right anterior abdominal wall and exited via right posterior wall, piercing the liver between segments 8 and 5 and creating a tract through segments 5 and 6 (AAST grade IV injury). There is active extravasation of contrast media consistent with arterial haemorrhage.
Large amount of free intraperitoneal high-density fluid - blood.

Radiographic evidence of haemoglobinopathy:

  • Surgical staples in left upper abdomen post-splenectomy.
  • Osteoporotic axial skeleton shows widened medullae with prominent trabeculation and thin cortices.
  • Bilateral paracostal-extrapleural, paraspinal, and presacral foci of extramedullary haematopoiesis throughout the chest.
  • Mildly H-shaped vertebrae (sagittal view)

CT head acquired 9 years earlier:

All bones of the skull display a widened medulla, with undeveloped frontal sinus and mastoid air cells and hypoplastic maxillary and sphenoid sinuses. Mucosal thickening in right maxillary and right ethmoidal sinus.
Calvarial bones show hair-on-end appearance

Radiographs obtained several years prior to the injury demonstrating widening of the ribs and pelvic bones and an osteoporotic vertebral trabeculation pattern. Surgical staples in left upper abdomen.

Case Discussion

Young male shot through the abdomen with an AAST grade 4 liver laceration showing active arterial bleeding.

Incidentally, the patient has a diagnosis of thalassaemia intermedia, a less severe form of beta thalassaemia major, where there is a relatively small amount of the β chain and haemoglobin A. Accompanying mental retardation and pervasive developmental disorder, mild pulmonary hypertension.
Underwent splenectomy of an enlarged spleen at age 13 due to recalcitrant anaemia, but to no avail (baseline haemoglobin level 8 g/dL). This, together with mildly H-shaped vertebrae seen on the sagittal view, could suggest coexisting sickle cell trait: haemoglobin sickle-beta thalassaemia (Hb S/β-thalassemia)

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Case information

rID: 55900
Case created: 28th Sep 2017
Last edited: 6th Nov 2017
Inclusion in quiz mode: Included
Institution: Hillel Yaffe Medical Center

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