Firearms injuries to the abdomen can affect multiple organs and can even traverse the diaphragm and cause thoracic injuries. Abdominal gunshot wounds may be isolated, but as in over one-quarter of these patients, there may be more than 1 injury present.92 Hollow-organ injuries are the most common, with the small bowel being the most commonly injured organ. Solid-organ injuries and genitourinary injuries are less common but must be considered and evaluated. Historically, many of these wounds mandated emergent exploratory laparotomy, but recently, more-conservative management plans have also been shown to have success.92,93
There are 4 anatomic zones of the abdominal cavity, which can help suggest the type of injury potentially present.92 (See Table 9.) Regardless of the external site of injury and the initial tract of the projectile, injuries can occur in remote sites due to ricochet and cavitary effects of the projectile. Because of the many possible intra-abdominal injuries, management of patients with abdominal gunshot wounds is based initially on physical examination and hemodynamic findings. Clearly, the unstable patient, the patient with an eviscerating injury, or the patient with peritonitis on examination will likely require operative intervention,94-96 but many of these patients are initially hemodynamically stable or unable to be assessed because they are sedated and intubated. In these less clearcut cases, diagnostic studies must be performed to help identify which patients can be managed nonoperatively and which patients require urgent exploratory surgery.