Gunshot to the Abdomen with Severe Hepatic Injury: Successful Non-Operative Management in a Resource-Constrained Setting

Introduction: Non-operative management is done for some carefully selected penetrating abdominal injuries. A thorough clinical examination is essential for screening and identifying patients without haemodynamic instability and peritonitis. Gunshot injuries undergoing non-operative management require detailed trajectory imaging with a CT scan. Isolated solid organ injury is not an absolute contraindication to non-operative management and may benefit from advanced endovascular and percutaneous interventions to facilitate management.  Objective: To encourage selective non-operative management of penetrating abdominal injuries to decrease the rate of unnecessary laparotomy, length of hospital stay and management cost.  Case Presentation: A 25-year-old man sustained a gunshot injury to the abdomen and was brought to our hospital after 18 hours. His chief complaint was abdominal pain. On the primary survey, he was haemodynamically unstable with respiratory insufficiency. He was resuscitated and stabilised. Abdomen shows asymmetric fullness over the epigastrium and right hypochondrium with a 1.5x1.5cm entry point on the epigastrium, 2x3cm exit point just anterior to the right posterior axillary line through the 11th intercostal space, tenderness over the right hypochondrium. Abdominal ultrasonography showed grade IV hepatic injury involving segments 4b, VII, and VIII. He was managed non-operatively with close monitoring and subsequently discharged home afterwards. His follow-up shows a stable patient with no complaints.  Conclusion: Prompt and accurate management of penetrating abdominal injury by resuscitation, close monitoring, investigation and follow-up is beneficial to most patients. Careful selection of these patients is necessary for good outcome.