Indirect ballistic injury to the liver: Case report and review of literature

Introduction: Penetrating injury due to gunshot wounds is a common problem seen in trauma centres around South Africa. Gunshot wounds can injure organs directly or may cause indirect injury. The temporary cavity is responsible for injury to organs distant to the wound tract. Organs with higher density such as bone or liver are more prone to injury due to the temporary cavity. Presentation of case: A 25 year old male patient sustained a gunshot wound to the right lower chest from a handgun. He was haemodynamically and metabolically stable with no evidence of peritonitis. CT scan of the abdomen revealed a Grade 2 injury of the liver. There was subcutaneous emphysema along the tract of the bullet. No injury to the lung or pleura was reported. The patient was explored laparoscopically to rule out diaphragmatic injury. At exploration the peritoneum was not breeched but the liver had a grade two laceration caused by an indirect ballistic injury Discussion: Penetrating trauma to the right lower chest can potentially injure multiple organs. CT scan can reliably diagnose the bullet tract as well as solid organ injuries. In this case the diaphragm was contused and the liver was lacerated by energy created by the temporary cavity. The difference in severity of the injury of these organs is related to the pliability of the tissue. Conclusion: Gunshot wounds can injure organs directly as well as those located close to the bullet tract. These injuries may be found in adjacent cavities not traversed by the bullet. A high index of suspicion, as well as imaging, is important to diagnose and grade these injuries. The possibility of indirect ballistic injury should always be kept in mind when managing patients with gunshot wound even in the lower velocity handgun injuries. (c) 2016 The Authors. Published by Elsevier Ltd on behalf of Surgical Associates Ltd. This is an open access article under the CC BY-NC-ND license (http://creativecommons.org/licenses/by-nc-nd/4.0/).