DELAYED PRESENTATION OF SMALL BOWEL INJURY FOLLOWING EXTRAPERITONEAL BALLISTIC INJURY

Objectives: Management of penetrating trauma to the abdomen has traditionally required laparotomies. Over the past decades, conservative management has been advocated in patients with no peritoneal violations. There have been few reports in adult trauma literature documenting injuries to the abdominal viscera following with extraperitoneal ballistic injury. Such injuries have been hypothesized to be secondary to the blast effect of the bullet. However, to our knowledge, no such cases have been described in pediatric trauma literature. Here, we discuss a case of delayed presentation of small bowel injury following extraperitoneal ballistic injury.

Our patient is a 4-year-old male who presented to our trauma bay after sustaining a gunshot to the abdomen. Vitals upon arrival were: pulse 84, blood-pressure 106/56, respiratory-rate 20, oxygen saturations 96% on non-rebreather. Initial fast exam was negative. Abdomen was soft, non-distended, but tender in right lower quadrant where a gunshot wound (GSW) was noted. GSWs were also noted in left medial thigh and left lateral thigh. Patient was taken to the operating room for wound exploration. These GSWs were in the same trajectory and no violation of the peritoneum was noted. Wounds were irrigated and then partially closed over a penrose drain. On POD1, patient was noted to be tachycardic and distended. Computed tomography imaging demonstrated pneumoperitoneum. Exploratory laparotomy was performed, and three separate perforations in 15 cm segment of mid- jejunum was noted. This was resected and anastomosed primarily. No other injuries were noted, and no violation of peritoneum was appreciated. Abdomen was closed. Patient did well in the post-operative period and was discharged on post-operative day 5.

Our case illustrates the importance of having blast effect in the differential. Blast injuries creates a contusion zone in the vicinity which can damage the blood vessels, nerves, and underlying viscera. Further research at the molecular level is warranted for better understanding of this phenomena.

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