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 catheterized 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 hemorrhage.
Large amount of free intraperitoneal high-density fluid - blood.

Radiographic evidence of hemoglobinopathy:

  • 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 hematopoiesis 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 IV liver laceration showing active arterial bleeding.

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

How to use cases

You can use Radiopaedia cases in a variety of ways to help you learn and teach.

Creating your own cases is easy.

Updating… Please wait.

 Unable to process the form. Check for errors and try again.

 Thank you for updating your details.