Swallowing the bullet: joe

Casualty Surgery Series

Swallowing the bullet: A gunshot to the right shoulder takes an unexpected turn

Desirae M. McKee, MD

Chief Surgical Resident

Department of Surgery

Todd C. Ruiter, DO

Surgical Resident

Department of Surgery

Bryan J. Hildebrand, CRC

Clinical Research Coordinator

Department of Surgery

Patrick J. O’Neill, PhD, MD, FACS

Surgical Attending

Division of Burns, Trauma Surgery, and Surgical Critical

Department of Surgery

Maricopa Medical Center

Phoenix, AZ

ABSTRACT

Introduction: Ballistic injuries may be diagnostically challenging because of the unpredictable trajectory of projectiles and the possibility of their migration via the enteric, vascular, genitourinary, or central nervous systems. To ensure that no internal damage goes undetected, surgeons must be prepared to consider injuries that may not match the radiographic or clinical findings.

Results and discussion: The authors report the case of a man who presented with a gunshot wound to the backside of his right shoulder. Computed tomography scanning showed a bullet in the patient’s stomach, and it was concluded that he swallowed it after it ricocheted off the scapula, traversed the trapezius muscle, and entered his hypopharynx. The bullet was successfully removed using a small anterior gastrotomy. Although this is the first case in the literature to describe a gunshot to the right posterior shoulder that resulted in an intragastric bullet without mediastinal, thoracic, diaphragmatic, or gastric injury, it constitutes another example in the literature documenting the unpredictable trajectory of ballistic projectiles.

Conclusion: Missed ballistic injuries maybe deadly, and surgeons should consider unusual trajectories or projectile migration whenever (1) an exit wound is not apparent; (2) there is discordance between the entrance wound and the site of the projectile on radiographs; and (3) the patient’s clinical condition and operative findings do not support the notion of a linear trajectory between the entrance wound and the projectile’s terminal location

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Ballistic injuries frequently produce unexpected findings due to the random trajectory paths of projectiles that often result in unusual terminal locations. Numerous case reports describe the ‘migration phenomenon,’ which refers to the unanticipated travel of a projective after it enters the victim’s enteric, vascular, genitourinary, or central nervous systems. We report the first case in the literature of a gunshot to the back of the right shoulder yielding an intragastric bullet yet causing no mediastinal, thoracic, diaphragmatic, or gastric injury, and, for all appearances, presenting as a swallowed bullet.

CASE REPORT

An oriented 22-year-old man self-ambulated into our level I adult and pediatric trauma center after sustaining a single ballistic wound to the right posterior shoulder on the superior border of the scapula. After the patient informed the triage nurse that he had been shot, he experienced a brief syncopal episode, which resolved just as medical personnel were approaching. He reported experiencing no loss of consciousness prior to his arrival and complained only of pain in the right shoulder and nausea.

Advanced trauma life support protocol was used to rapidly move the patient to the trauma bay, where he was resuscitated. The patient had an intact airway, an initial systolic blood pressure of 64 mm Hg, and a sinus bradycardic heart rate of less than 60 beats per minute, which corresponded to the resolving syncopal episode. Breath sounds were equal bilaterally, and there was no chest crepitance on auscultation or palpation. Bilateral, large-bore intravenous access of the upper extremity was obtained, and the patient’s hypotension resolved shortly after he received a crystalloid infusion.

The patient’s physical examination was significant for diaphoresis, a small amount of blood in his mouth from a minute tongue laceration, which occurred when he bit his tongue after being shot, and a posterior right suprascapular ballistic wound. His abdomen was nontender to palpation. A drug screen was positive for alcohol, cannabis, and amphetamines. The neurovascular examination of all 4 extremities was normal. His cranial nerve examination was nonfocal; however, he did have some trapezius pain upon shrugging his right shoulder.

An expedient trauma workup ensued. Chest and abdominal radiographs demonstrated that the projectile had crossed the midline and was lodged somewhere in the mid-torso on the left (Figure 1). Subcutaneous air, which had not been evident on physical examination, was observed in the right neck and upper chest. The patient remained hemodynamically stable, and his vagal episode subsided completely. Because of the paucity of physical examination findings and the patient’s normal vital signs, we decided to perform computed tomography (CT) scanning of his chest, abdomen, and pelvis. CT scanning confirmed subcutaneous air in the right neck and upper chest (Figure 2) and showed a metallic object in the stomach (Figure 3). Both lung fields and the mediastinum were normal, but there was a comminuted right scapular fracture underlying the ballistic wound and air tracking through the right trapezius muscle. No intraabdominal free fluid or extraluminal air was evident.

Because of the subcutaneous air noted in the patient’s neck, he was immediately taken to the operating room and underwent endotracheal intubation. Bronchoscopy was performed but no tracheobronchial injury was identified. The right side of his neck was explored through the standard anterior sternocleidomastoid incision, and no injuries to the vital airway, vascular, or nervous structures were noted. The retropharyngeal space was examined, which identified a laceration on the right side of the hypopharynx. The patient underwent an esophagogastroduodenoscopy but no additional signs of injury were observed distal to or opposite the laceration on the right side of the hypopharynx. A primary two-layer repair of the hypopharynx was performed, leaving a closed-suction drain in place.

A limited exploratory laparotomy confirmed the absence of any intraabdominal injury. The bullet removed using a small anterior gastrotomy, through which a feeding gastrostomy tube was placed to allow oropharyngeal diversion. The abdomen was closed, and the patient was started on tube feedings immediately following surgery. His postoperative recovery was uneventful, and after 5 days, a fluoroscopic swallow study showed no hypopharyngeal leaks, allowing the closed-suction drain to be removed. About 1 week after admission, the patient was discharged to home tolerating a regular diet. The gastrostomy tube was removed at a follow-up appointment.

DISCUSSION

Gunshot injuries are not uncommon in urban areas. In 2000, approximately 29,000 people in the United States died from firearm injuries, which accounted for up to 20% of trauma-related deaths.^1,2 Interpreting the unpredictable and often contradictory clinical findings in ballistic trauma patients requires dynamic analysis, but it is imperative if morbidity and mortality are to be prevented. Providing acute surgical care to gunshot victims necessitates a standardized and well-rehearsed team approach, under the direction of the trauma surgeon.

Projectile trajectory—Bullets that penetrate the human body usually travel in a straight line, but many factors can cause the projectile to deviate from a linear trajectory.³ In our patient’s case, we postulate that the projectile lost its kinetic energy after it fractured and ricocheted off the right scapula, causing it to traverse the trapezius muscle and enter the right side of the patient’s hypopharynx from the rear. Once the bullet entered the hypopharnyx, the patient reflexively swallowed it, which resulted in an intragastric projectile yet no evidence of mediastinal, thoracic, diaphragmatic, or gastric injury. Although this case appears to be the only one in the literature of an intragastric ballistic fragment without concomitant esophageal or gastric injury, it contributes to the body of literature highlighting the variable and unexpected behavior of projectiles after they enter the human body. Projectile fragments are known to have entered and migrated within the enteric, vascular, central nervous, and genitourinary systems. This random behavior often results in contradictory physical examination findings and diagnostic confusion.³

Enteric migration—Esophageal injuries from projectiles have been described in the literature. Hughes reported the case of a patient who presented with a gunshot wound to the right side of the chest just below the nipple and was found to have an esophageal injury.⁴ An initial chest radiograph demonstrated an intraabdominal projectile in the right upper quadrant, and despite the patient’s stable condition, it was assumed that the bullet entered the abdomen by traversing the patient’s chest on the right and diaphragm. Laparotomy found no projectile or diaphragmatic injury, and all abdominal organs appeared to be normal. A postoperative CT scan confirmed the bullet’s intra-enteric location, and a subsequent contrast-swallow study and direct visualization upon thoracotomy demonstrated an esophageal perforation. The patient passed the projectile in his fecal stream several days postoperatively.⁴

Desai and Hutchins reported the case of a hemodynamically stable patient who was shot in the right side of the chest but had no exit wound. Plain radiography showed the bullet lodged midline at the L3 level. The authors elected conservative management and monitored the patient closely using serial radiographic examinations. The patient remained stable, and serial abdominal radiographs confirmed projectile migration to the right iliac fossa. CT scanning confirmed the bullet’s position within the lumen of the cecum. A contrast study of the esophagus failed to demonstrate esophageal perforation. Four days later, the bullet was recovered from the patient’s stool, and he recovered well without surgery. Another report describes acute appendicitis resulting from a bullet that migrated to the appendix 9 years after the patient was shot.⁵ The literature contains other reports of enteric migration and evacuation of projectiles, as well as reports of intrathoracic projectiles that exited through the bronchial tree.^6-8

Vascular migration—Migration of missile fragments via the vascular system is well-recognized, but this complication is rarely encountered in patients with gunshot wounds.⁹ When such migration does occur, it often involves the heart or vena cava and causes venous embolization.¹⁰ Retrograde venous embolization, albeit rare, also has been documented, as has paradoxical missile migration through a patent foramen ovale.^10-12 Arterial emboli passing from cardiac, pulmonary venous, or aortic entry sites to the coronary circulation system and periphery have been well-described.^13-16

Central nervous system migration—The central nervous system represents another described route of projectile migration, and bullets and bullet fragments are known to have migrated throughout the brain and spinal canal.^17-20 In most cases, these projectiles travel caudally and their migration takes months or years. Bullets that penetrate the spinal canal and later migrate spontaneously do not always produce significant neurological deficits or require surgical intervention.²¹

Genitourinary migration—Cases have been reported of bullet migration via the urinary system.^22-25 Patients typically present with symptoms of renal colic. Small bullet fragments, much like renal stones, pass uneventfully, but emboli larger than 7 mm may require operative extraction.^23,24

When to suspect projectile migration—Determining the path a bullet or missile fragment has taken after entering the body can be challenging, if not impossible. Based on our review of the literature, we suggest that surgeons consider projectile migration whenever (1) an exit wound is not apparent; (2) there is discordance between the site of the projectile on radiographs and the entrance wound; and (3) the patient’s clinical condition and operative findings fail to support the notion of a linear trajectory between the entrance wound and the projectile’s terminal location

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CONCLUSION

Our case report serves as a reminder that bullets do not always travel in a straight line and that a ballistic projectile’s terminal behavior becomes unpredictable once it enters the human body. Trauma surgeons must remain vigilant and alert to alternative explanations when facing contradictory or confusing radiographic or clinical findings. Because of the migration phenomena, imaging studies must be conducted or repeated before undertaking operative exploration for a retained projectile.

Practice Points

• When a patient has been shot but no exit wound is evident, surgeons should consider the possibility that the bullet has migrated.

• It is important for the surgeon to determine the bullet’s complete trajectory to ensure that no internal damage is overlooked.

• When a projectile is believed to have been retained, imaging studies are essential prior to operative intervention.

References

1. Hackam DJ, Mazzioti MV, Pearl RH, et al. Mechanisms of pediatric trauma deaths in Canada and the United States: the role of firearms. J Trauma. 2004;56:1286-1290.

2. Schwab CW, Richmond T, Dunfey M. Firearm injury in America. LDI Issue Brief. 2002;8:1-6.

3. Ledgerwood AM. The wandering bullet. Surg Clin North Am. 1977;57:97-109.

4. Hughes JJ. Bullet injury to the esophagus detected by intestinal migration. J Trauma. 1987;27:1362-1364.

5. Horby-Petersen J, Kristiansen T, Jelnes R. Acute appendicitis caused by metallic foreign body (bullet). Case report. Acta Chir Scand. 1987;153:697-698.

6. Montano JN, Mandal AK, Lou MA, et al. A “wandering bullet” in the thoracic esophagus. J Natl Med Assoc. 1983;75:835-836.

7. de Bree E, Michalakis J, Melissas J, et al. Spontaneous transanal bullet discharge following pelvic gunshot injury. ANZ J Surg. 2004;74:82.

8. Saunders MS, Cropp AJ, Awad M. Spontaneous endobronchial erosion and expectoration of a retained intrathoracic bullet: case report. J Trauma. 1992;33:909-911.

9. Ronsivalle J, Statler J, Venbrux AC, et al. Intravascular bullet migration: a report of two cases. Mil Med. 2005;170:1044-1047.

10. Golkar RR, Bryant HH, Ghahramani AR, et al. Bullet embolization to the heart. Report of a case and review of the literature on indications for removal of intracardiac foreign bodies. J Cardiovasc Surg (Torino). 1975;16:327-330.

11. Bertoldo U, Enrichens F, Comba A, et al. Retrograde venous bullet embolism: a rare occurrence-case report and literature review. J Trauma. 2004;57:187-192.

12. Schurr M, McCord S, Croce M. Paradoxical bullet embolism: case report and literature review. J Trauma. 1996;40:1034-1036.

13. Hopkins HR, Pecirep DP. Bullet embolization to a coronary artery. Ann Thorac Surg. 1993;56:370-372.

14. Bilsker MS, Bauerlein EJ, Kamerman ML. Bullet embolus from the heart to the right subclavian artery after gunshot wound to the right chest. Am Heart J. 1996;132:1093-1094.

15. Burkitt DS, Dhasmana JP, Mortensen NJ, et al. “Bullet embolism” to the popliteal artery following air rifle injury of the thoracic aorta. Br J Surg. 1984;71:61.

16. Chapman AJ, McClain J. Wandering missiles: autopsy study. J Trauma. 1984;24:634-637.

17. Gupta S, Senger RL. Wandering intraspinal bullet. Br J Neurosurg. 1999;13:606-607.

18. Zafonte RD, Watanabe T, Mann NR. Moving bullet syndrome: a complication of penetrating head injury. Arch Phys Med Rehabil. 1998;79:1469-1472.

19. Kafadar AM, Kemerdere R, Isler C, et al. Intradural migration of a bullet following spinal gunshot injury. Spinal Cord. 2006;44:326-329.

20. Karabagli H. Spontaneous movement of bullets in the interhemispheric region. Pediatr Neurosurg. 2005;41:148-150.

21. Rajan DK, Alcantara AL, Michael DB. Where’s the bullet? A migration in two acts. J Trauma. 1997;43:716-718.

22. Bozeman WP, Mesri J. Acute urinary retention from urethral migration of a retained bullet. J Trauma. 2002;53:790-792.

23. Eickenberg HU, Amin M, Lich R Jr. Traveling bullets in genitourinary tract. Urology. 1975;6:224-226.

24. Kilic D, Kilic F, Ezer A, et al. Spontaneous expulsion of a bullet via the urethra. Int J Urol. 2004;11:576-577.

25. Miller JT, Scheidler MG, Miller R, et al. Cystoscopic removal of a large-caliber bullet from the left ureter: a case report of missile migration after a gunshot wound. J Trauma. 2004;56:1141-1143.

Figure 1—Anteroposterior abdominal radiograph demonstrating a projectile in the left upper quadrant.

Figure 2—CT scan (bone windows) with intravenous contrast showing extensive fascial and subcutaneous air throughout the right side of the patient’s neck and upper chest. Note the contrast in the right subclavian vein.

Figure 3—CT scan (bone windows) with intravenous contrast showing an intragastric metallic foreign body.

Practice Points

Acute care for gunshot victims requires a standardized, team approach supervised by the trauma surgeon.

Interpreting unpredictable or contradictory findings in ballistic trauma patients requires dynamic analysis.

Consider migration any time radiographic findings of the projectile’s terminal location are inconsistent with the entrance wound or when there is no exit wound.

Because retained projectiles can migrate, surgeons should conduct or repeat imaging studies before operative exploration.

Retained bullets or bullet fragments have been known to undergo enteric, vascular, genitourinary, central nervous system, and vascular migration.

[Callouts, if needed]

(1^st sentence of discussion)

Bullets that penetrate the human body usually travel in a straight line, but many factors can cause the projectile to deviate from a linear trajectory

[Under projectile trajectory]

Once the bullet entered the hypopharynx, the patient reflexively swallowed it…

Projectile fragments are known to have entered and migrated within the enteric, vascular, central nervous, and genitourinary systems.