A Case of a Bullet Penetrating the Esophagus: 589

Purpose: We present a case of a bullet visualized during endoscopy after gun shot wound in which no surgical or endoscopic intervention was needed for a good outcome. Results: Patient is a 21 year old female with recent gun shot injury who came to emergency room complaining of epigastric pain. One month ago, she presented with gun shot wounds and was found to have three bullet fragments in her body-two fragments in her left leg and one large fragment between the esophagus and aorta without extravasation from heart, aorta or great vessel. Barium swallow study did not show any esophageal injury at the time. She had multiple medical complications during that hospitalization, including pneumomediastinum, right hemothorax and pneumothorax, and posterior mediastinal hematoma. Surgical removal of this bullet fragment was not done due to difficult positioning and risk associated with operative intervention. During the most recent admission, the patient presented with epigastric pain and nausea that became progressively worse the last few days. Swallowing exacerbated the pain. She denied difficulty protecting her airway, dysphagia, emesis, hematemesis, or hemoptysis. Initial CT scan was concerning for shift in position of bullet compared to previous imaging. Gastroenterology team was consulted, as it was difficult to discern if the bullet penetrated the esophagus. EGD was performed and the bullet was seen embedded in mucosa of the lower esophagus. Gastrograffin esophagram did not show any contrast extravasation. Aortogram showed no focal aortic or arterial injury. The surgery team discharged the patient without surgical intervention, as she was tolerating a diet and did not have evidence of vasculature injury. Few weeks later, plain films showed the bullet having migrated into the small intestine. One week later, the bullet was in the left colon. EGD and flexible sigmoidoscopy were performed without retained bullet. Esophageal mucosa was completely normal without any abnormalities. Conclusion: This is a case of a bullet that fully penetrated the esophagus over time without any complications. No surgical or endoscopic intervention was required, with the esophageal mucosa healing completely on its own.Figure 1