Caceres’ Corner Case 163 (Update: Solution)

Dear Friends,

Welcome to the sixth season of Cáceres’ Corner. I will present cases during the month of September because Dr. Pepe is vacationing in Menorca with Miss Piggy and will not start the Diploma cases until October.

My close friend Larry Goodman, Director of Chest Imaging at the Medical College of Wisconsin, provides the first case. The images are of a 27-year-old male who was shot in the abdomen. I am showing chest radiographs taken on admission and after a CT was performed.

What do you see?

Check the images below, leave your thoughts in the comments section, and come back on Friday for the answer.

Click here for the answer

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    Sep 2017
    DISCUSSION 25 Comments

    25 Responses to : Caceres’ Corner Case 163 (Update: Solution)

    1. Borsuk says:

      Hello after holiday dear professor:)
      On second picture I think about deep sulcus sign on left in pneumothorax.
      Is that metalic object a bullet? I dont know why its moving – inside gi tract?

      • Jose caceres says:

        Welcome back, dear friend. Don’t you think that the bullet in the chest is too high to be in the stomach?

        • Borsuk says:

          That’s truth it’s above diaphragm. In the absence of hernia or rupture of diaphragm – I can’t see any signs of it – it’s too high to be in the stomach.
          Quite strange bullet journey. In clinical history patient was shot in the abdomen – maybe it’s come back by bullet track in chest-abdomen walls?

    2. Olena says:

      there are the shadows of ecg electrodes seen on both side

      on the right there is a small apical pneumothorax on the first AP chest radiograph on admission

      and the “bullet-like” shadow on the left overlaying the shadow oh the posterior part of 9 rib – I suppose this shadow has too smooth and well-defined contours to be a bullet

    3. Olena says:

      on the second chest x-ray we can see the contrast in calyces and renal pelvis of both kidneys with further contrast in left ureter. at the same time it seems there is no enhanced the write ureter (ruptured ?) closer to vertebral column on the level of the Th12 on the right side there is seen the probable bullet of oval shape

      • Olena says:

        is this bullet in the kidney?

        • Jose Caceres says:

          I am not confirming or denying it. How do you explain it got there?

          • Olena says:

            it will sounds absurdly but maybe the bullet was in the left ventricle and with the blood flow traveled?
            the bullet could be small enough

            silly, I suppose?

            • José Cáceres says:

              Not silly at all. Let us pause the discussion and return to it tomorrow. In the meantime, think about the bullet

            • Olena says:

              I read about the bullet embolism but from heart to pulmonary vessels – they are big enough.
              in this case the only vessel I can think about is right renal vessel but according normal anatomy it is too small – 5-6mm in diameter

      • Jose Caceres says:

        Welcome, dear Olena. The bullet is definitely a bullet. While in USA, I saw many of them.
        CT did not confirm a pneumohorax, nor did it show any problem with the ureter

        • Olena says:

          soft tissue, lung parenchima look normal
          there is no tear of diaphragm and the air in the addomen

          no rib fractures

          she is intubated and has nasogastral probe

          is there a wrong position of the right subclavian cathether (if it is a cathether and not any other external device)?

    4. Mónica says:

      Welcome Dr. Cáceres!!!

      Is it possible that the bullet was outside the body??

    5. Mk says:

      Welcome Dr. Cáceres!!!

      Is it possible that the bullet was outside the body??

      • José Cáceres says:

        Very good idea. Sorry, bullet is inside the body

        • Mk says:

          In the second X-ray there is an increased convex density under the left diapgrahm that is pushing the stomach (nasogastric tube is displaced laterally) and the kidney. Perhaps there is a postero-inferior haemathoma…..

    6. TR says:

      in the admission radiograph, the bullet can be in three possible locations: inside the heart, posterior or anterior to it, so if it was the inside the heart, then it seems that it has migrated within the great vessels to the abdomen, the renal excretion looks symmetrical?, so there a low possibility that the right renal vessels are affected.
      And if it was posterior or anterior to the heart then it has migrated to the abdomen through a diaphragmatic defect, which is expected in this case.
      so the bullet has migrated though a diaphragmatic defect or within the great vessels.


      • Jose Caceres says:

        You deserve to know that the bullet was located in the right ventricle in the admission film. This raises two interesting questions:
        1. Considering that the patient was shot in the abdomen, how did it get there?
        2. How did it travel from the RV back into the abdomen? (second chest film)

    7. TR says:

      there are two possibilities how it reached the RV:
      -through the IVC.
      -directly through the diaphragm and RV ventricular wall, although no evidence of hemopericarduim, but there is mild widening of the superior mediastinum in the second film compared to the first.

      There are two possibilities how it migrated back to the abdomen:
      – through the aorta, which makes sense because of the blood flow direction, but in this case a R-L shunt is needed, either congenital or traumatic.
      – through the IVC, in this case it must have been regurgitated through the tricuspid valve and the gravity drove it down against the flow direction.


    8. Borsuk says:

      Ad.2 Could be pushed back by IVC after CPR.

    9. genchi Bari Italia says:

      ….avevo dimenticato la lunga vacanza….scusa per il ritardo………il tragitto del proiettile è stato dal basso verso l’alto e quindi, attraverso lo stomaco è giunto nel ventricolo dx… contrattilità del cuore, evidentemente, lo ha risospinto nello stomaco, perchè probabilmente era rimasto intrappolato nella parete ventricolare, ma non proprio nella cavità—–con cari saluti da Bari.

    10. sabry says:

      hyper ventilation left upper lobe lung with wide inter costal spaces
      Lt sternoclaviular joint not clearly defined ( fructure)