A 32-year-old male presents to the emergency department 2 hours after sustaining a gunshot wound to the left lower abdomen. Vital signs are stable; abdominal examination reveals a single entry wound with minimal bleeding. There is no exit wound. Plain radiography shows the bullet lodged in the pelvis. The patient is haemodynamically stable with normal bowel sounds. What is the most appropriate next step in management?

Explanation

## Clinical Context A haemodynamically stable patient with a penetrating abdominal gunshot wound requires imaging to determine the trajectory and extent of organ involvement before surgical decision-making. ## Key Point: **In a stable patient with penetrating abdominal trauma, CT imaging is the gold standard for trajectory assessment and organ injury detection.** It guides the decision between operative and non-operative management. ## Management Algorithm for Penetrating Abdominal Gunshot Wounds ```mermaid flowchart TD A[Gunshot wound to abdomen]:::outcome --> B{Haemodynamically stable?}:::decision B -->|No| C[Immediate exploratory laparotomy]:::action B -->|Yes| D[CT abdomen/pelvis with contrast]:::action D --> E{Peritoneal penetration + organ injury?}:::decision E -->|Yes| F[Exploratory laparotomy]:::action E -->|No| G[Serial clinical exam + observation]:::action G --> H{Signs of peritonitis develop?}:::decision H -->|Yes| I[Delayed laparotomy]:::action H -->|No| J[Discharge with follow-up]:::outcome ``` ## Why CT is Preferred | Modality | Advantage | Limitation | |----------|-----------|------------| | **CT with contrast** | Detects solid organ injury, retroperitoneal bleeding, trajectory; guides selective non-operative management | Requires transport; not for unstable patients | | **Diagnostic peritoneal lavage** | Rapid; detects peritoneal penetration | Cannot assess retroperitoneum; high false-positive rate; largely replaced by FAST/CT | | **Exploratory laparotomy** | Definitive; therapeutic | Invasive; unnecessary if no peritoneal injury | ## High-Yield: **Selective non-operative management (NOM) is now standard for haemodynamically stable patients with penetrating abdominal trauma**, provided imaging excludes peritoneal penetration with organ injury. Mandatory exploration is reserved for unstable patients or those with peritonitis. ## Clinical Pearl: The trajectory of the bullet (determined by entry/exit wounds and imaging) is critical. A bullet lodged in the pelvis may have traversed bowel, bladder, or major vessels—CT clarifies this before any decision to observe.