Gunshot wound to the abdomen with injury to the SMA and active extravasation

Discussion:

Teaching points:

  • Use the scout images to identify entry and exit wounds (with paperclips). The pathway of the bullet can be highly variably and unpredictable, but following the course of the bullet will help you to identify all of the key injuries. 
  • The injury to the SMA with active extravasation is pretty obvious. It is important to identify where the injury is and what branches are affected: the ileocolic artery is intact, and therefore there is flow in the cecum and terminal ileum. However the distal ileal branches are out. Therefore, when you follow the TI retrograde, it ends up in indistinct hypoenhancing ileum in the right lower quadrant. This largely blends in with the hemoperitoneum, and is barely noticeable until you follow the leaves of the mesentery out and look for the ileum. There is a lot of bowel that is not enhancing! 
  • Clefts in the liver and spleen can mimic lacerations. 
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