An interesting case

The patient is a 28- year old male who arrived with multiple GSW. Primary survey was intact. Secondary survey revealed 7 GSW’s: 2 wounds were on his right lateral thigh, 2 wounds were on his right medial lower leg, 1 wound on his proximal left thigh with an obvious thigh deformity, 1 wound on his distal left thigh, and 1 wound on his left proximal scrotum with extravasation of tissue. Plain films showed a retained bullet in the scrotum, a left comminuted femur fracture, and a left proximal tibial fracture.  Chest xray/pelvis xray/right femur xray/ abd xray/CT angiogram of left leg/RUG/cystogram all showed no abnormalities. Abdominal exam was normal. 

On the day of admission he went to the OR for a scrotal exploration, repair of left corpora, and bulletectomy. On the following day, he underwent a closed reduction and intra- medullary nailing of his left femoral shaft fracture. He did well until Post-op day 4, when he started having emesis  His abdominal exam remained normal. Abdominal xray showed non- obstructive gas pattern, WBC was 13. The following morning, the patient left AMA.

A few days later, the patient re- presented with persistent nausea and emesis over the last 24 hours, but was passing gas/bowel movements, and denied abdominal pain. Denied fevers. Exam continued to show neither abd tenderness nor distension, and pt was afebrile, despite a  WBC over 20. CTAP showed a large right- sided fluid collection with a small amount of free peritoneal air.  The patient was taken to the operating room. 

Exploratory laparotomy showed a large collection of infected looking material and 6 injuries to the proximal / distal jejunum, and proximal ileum, that were primarily repaired. On exploration there was an inguinal hernia present. We hypothesize that when he was originally shot in the scrotum, his hernia contained bowel, which was therefore injured. Postoperatively this patient recovered well and was discharged home. Interestingly, the patient did not show any signs of intrabdominal injury on presentation or for the first few days after being admitted. 

The take home lesson is that for any male who is presenting with a scrotal injury, history of inguinal hernia should be part of the HPI. If there is a history of hernia, DPL to evaluate for intestinal injury might be warranted.

from Dr. Ben Shogan