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Mon Dec 31 18:29:47 GMT 2007

I think that I would have scanned the gent, and with no active extravisation/bleeding or hollow viscus injury (i.e. a clearly transhepatic wound) I would have watched him and treated any subsequent collections with percutaneous drainage and perhaps a stent to facilitate hepato-enteral drainage.

Ron

>>> "Errington Thompson" <errington at erringtonthompson.com> 12/30/2007 12:06 AM >>>
I have a couple of questions on a recent case.  30 yo male was too drunk to
have a gun but had one nonetheless.  He shot himself in the right upper
quadrant.  He was stable, awake and talking in the ER.  Entrance wound
easily seen just under the ribs and just lateral to the mid-clavicular line.
The bullet was palpable just under the skin at about the 12th rib.  No SOB.

1) CT or not CT scan.  IF you do scan the patient and see a thru and thru
wound the liver, can you just watch him?

I take the patient to the OR.  He indeed has a thru and thru GSW to the
liver.  The wounds are not really bleeding.  There is no bile oozing from
either wound.

2) Drain or no drain?

The patient develops an ileus and bile peritonitis.  He is percutaneously
drained.  On day 5 with his drain output still over 300 cc per day the
character of the drainage changes to a dark green.  CT scan revealed an
abscess posterior to the liver.  Percutaneous drainage was performed.
Enterococcus in the fluid.  Antibiotics were started.  Antiobiotics stopped
after 7 days. 

Thoughts?

Errington C. Thompson, MD, FACS, FCCM
Trauma/Surgical Critical Care
Mission Hospital
Asheville, NC
Author - A Letter to America
www.whereistheoutrage.net 

Everyone deserves to make an informed decision
                                - Errington Thompson, MD

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GSW to liver