What Happens if a Bullet Is Left in the Body?

Most bullets that remain in the body after a gunshot wound are never removed, and in the majority of cases they cause no serious long-term harm. The body typically walls off a retained bullet inside a capsule of scar tissue, isolating it from surrounding structures. That said, retained bullets are not biologically inert, and the complications they can produce range from slow-onset lead poisoning to bullet migration through blood vessels. Whether a bullet should stay or go depends heavily on where it ended up.

Why Surgeons Usually Leave Bullets Alone

It sounds counterintuitive, but digging out a bullet often does more damage than the bullet itself. A projectile that has come to rest in soft tissue, away from any joint or major vessel, gets quickly surrounded by avascular scar tissue. Once encapsulated, its contact with living tissue is minimal, and the risk of infection or lead absorption drops sharply. Formal exploration and removal in these cases can tear through muscle, fascia, and nerves that the original wound track may have spared. For low-energy gunshot wounds where the bullet sits in soft tissue, standard practice is to leave it in place.¹

High-energy wounds are a different story. These typically shatter tissue so extensively that surgeons need to debride the wound regardless, and removing the bullet during that cleanup adds little extra trauma. But the general principle holds: if a bullet cannot even be felt through the skin and is sitting quietly in muscle or fat, trying to extract it is hard to justify.

When Removal Is Necessary

There are a handful of situations where leaving a bullet in place creates a clear and ongoing danger. European clinical practice guidelines identify a short list of firm indications for removal: bullets lodged inside a joint, within the cerebrospinal fluid, or in the globe of the eye. Fragments compressing a nerve or nerve root, and bullets sitting inside the channel of a blood vessel where they could block blood flow or break loose and travel, also warrant extraction. A rarer but recognized indication is when a retained bullet is causing lead poisoning, and occasionally removal is needed to preserve forensic evidence in criminal investigations.²

Beyond these scenarios, the decision gets murkier. A bullet on a weight-bearing surface like the sole of the foot or the palm of the hand is usually removed after swelling resolves, since daily pressure would cause chronic irritation. Bullets in a bursa, the small fluid-filled sac near a joint, are also typically taken out. In all other locations, surgeons weigh the risks of the operation itself against the risks of leaving the bullet where it is.¹

Lead Poisoning From Retained Bullets

Most conventional ammunition contains lead, and when a lead bullet sits in soft tissue wrapped in scar tissue, the amount of lead that leaches into the bloodstream is usually negligible. The real danger begins when a bullet ends up in a joint. Synovial fluid, the lubricant inside joints, actively dissolves lead. The acidity of that fluid and the presence of hyaluronic acid both accelerate the process.³ Historically, every documented case of bullet-related lead poisoning in the United States involved a bullet sitting in contact with synovial fluid, often dissolving slowly over years or even decades.⁴

The symptoms can be maddeningly vague: unexplained anemia, crampy abdominal pain, kidney problems, or a slow cognitive decline that nobody connects to an old gunshot wound. Because lead poisoning from a retained bullet can surface months or years after the injury, the connection is easy to miss.⁵ One published case described a patient with a bullet lodged near the lumbar spine who was admitted to the hospital repeatedly over a decade for confusion and blood lead levels exceeding 100 micrograms per deciliter, roughly twenty times what is considered elevated.⁶

Several factors raise the risk. More fragments mean more surface area exposed to body fluids. A nearby fracture can increase lead absorption, possibly because the healing bone draws in more blood flow. Any hypermetabolic state, including pregnancy, illness, or rapid weight loss, can mobilize lead that has been quietly stored in bone and soft tissue. And the longer a bullet remains, the greater the cumulative exposure.⁵ Even soft-tissue bullets, which are generally considered low risk, have on rare occasion produced dangerously high blood lead levels. One patient with fragments retained in the leg from a wound ten years earlier presented with a blood lead level above 200 micrograms per deciliter, a level that can cause seizures and organ failure.⁷

When lead poisoning is confirmed, treatment usually combines chelation therapy, which binds circulating lead so the kidneys can flush it out, with surgical removal of the bullet when feasible. In one case of a patient with retained intracranial bullet fragments who developed tingling in the hands and thighs, abdominal cramping, mood swings, and intermittent psychosis, removing the fragments brought blood lead levels down and resolved the symptoms.⁸

When Bullets Travel After the Shooting

A bullet does not always stay where it lands. If a projectile enters or comes to rest against a blood vessel, blood flow can carry it to an entirely different part of the body, a phenomenon called bullet embolization. Arteries are involved in roughly four out of five cases. When a bullet embolizes through an artery, it tends to lodge in a smaller downstream vessel and cut off blood flow to a limb or organ, creating an emergency. Venous emboli behave differently: the bullet drifts with blood returning to the heart. About half of venous bullet emboli end up in the right side of the heart, with most of those getting stuck in the right ventricle. Another third reach the pulmonary arteries in the lungs.⁹

Embolization can happen within minutes. One documented case showed a bullet fragment that was initially seen overlying the heart on imaging but had migrated to the left common iliac vein by the time a follow-up scan was taken just thirteen minutes later.¹⁰ For patients with bullets near major vessels, this risk makes a strong argument for early removal. A review of conservative management in people with venous bullet emboli who had no symptoms found that a quarter eventually developed complications, and three of those observed patients died.¹¹ That is a sobering complication rate for a strategy built around watching and waiting.

Retained Bullets and MRI Scans

One of the most common concerns people have after being told a bullet will stay in their body is whether they can ever get an MRI. The answer depends on the bullet’s composition. Most civilian handgun ammunition is made of lead, sometimes with a copper jacket, and neither of those metals is strongly attracted to a magnet. Testing at multiple MRI field strengths showed that bullets and pellets without a steel core did not move at all in the magnetic field, even at very high strengths. They also produced only small image distortions. Bullets with a steel core, however, moved enough to be considered unsafe, and created massive image artifacts that made the scan useless in the surrounding area.¹²

The practical problem is that patients often do not know what they were shot with, and imaging alone cannot reliably distinguish steel-containing projectiles from others. This means doctors usually err on the side of caution, ordering CT scans or X-rays instead of MRIs for people with retained bullets, at least until the composition can be reasonably inferred. Even with non-magnetic bullets, the metal creates signal voids on MRI that obscure nearby structures, limiting the scan’s diagnostic value in the affected area.

Imaging Challenges Beyond MRI

CT scans are safer for people with retained bullets, but they come with their own problems. Metal produces artifacts on CT, bright streaks and dark shadows that radiate outward from the bullet and obscure the surrounding anatomy. These artifacts can hide critical injuries along the bullet’s path or mask developing problems near the fragment.¹³ Newer iterative reconstruction algorithms have improved things, but the artifacts have not been eliminated. Forensic investigators face a related challenge: the CT appearance of a retained bullet cannot reliably identify the type of ammunition or its composition, because the beam-hardening effects distort the measured density of the metal itself.¹⁴

Psychological and Quality-of-Life Effects

The physical complications of a retained bullet get most of the medical attention, but the psychological effects are real and often overlooked. A study comparing gunshot survivors with and without retained bullets found that those carrying a bullet had significantly more severe symptoms of depression three months after discharge, even after adjusting for how badly they were injured. The retained bullet itself, and the number of wounds, were independent predictors of depressive symptoms.¹⁵ The same study found no significant difference in PTSD symptoms between the two groups, suggesting that carrying a physical reminder of the trauma affects mood through a pathway distinct from classic post-traumatic stress.

Qualitative research with gunshot survivors fills in the picture. People describe the retained bullet as affecting four broad areas of their lives: ongoing pain and limited mobility, emotional difficulties like anger and fear, social withdrawal, and the inability to work or maintain financial stability.¹⁶ The bullet becomes a permanent, tangible connection to the event, and for some people that connection is harder to process than the memory itself.

Children and Retained Bullets

Pediatric patients face additional risks that adults do not. Children have growth plates, the areas of developing cartilage near the ends of long bones, and a bullet that passes close to a growth plate can disrupt normal bone growth even without making direct contact. In limited studies, injuries to the growth plate occurred in about one in six pediatric gunshot wound cases.¹⁷

Children are also at higher risk for lead toxicity, partly because a bullet retained in childhood will be present for a much longer portion of the person’s life, giving lead more time to accumulate. A child’s smaller body mass means a given dose of lead produces higher blood concentrations, and the developing brain is more vulnerable to lead’s neurotoxic effects. The CDC’s threshold for an elevated blood lead level in children was lowered to 3.5 micrograms per deciliter in 2021, down from 5 in 2015, underscoring how seriously even modest lead exposure is now taken.¹⁷ For these reasons, the threshold for removing a retained bullet is generally lower in pediatric patients.

Copper-Jacketed Rounds and Other Metal Concerns

Lead is not the only metal that matters. Many bullets are copper-jacketed, and copper appears to be more biologically toxic than bare lead when it comes to the central nervous system. Research on copper-jacketed bullets lodged in the brain found that the copper component sometimes caused the bullet to migrate through brain tissue, something rarely seen with unjacketed lead projectiles.¹⁸ This is a concern primarily for bullets retained in or near the brain and spinal cord, not for those in peripheral soft tissue. Military ammunition, which often contains steel cores or unusual alloys, introduces its own set of unknowns around long-term corrosion and tissue reaction.

Retained Bullets and Cancer

An uncommon but documented long-term complication is the development of a tumor at the site of a retained bullet or fragment. Case reports exist of skeletal sarcomas arising at the location of old retained war fragments in the limbs, and a literature review has found similar instances across different cancer types.¹⁹ More recently, a case of small cell lung cancer developing after a gunshot wound to the chest has been reported, adding to a small collection of published cases linking chronic tissue trauma and foreign bodies to malignancy.²⁰

This does not mean a retained bullet meaningfully raises a person’s cancer risk. The number of reported cases is tiny compared with the enormous number of people walking around with retained fragments. But the mechanism is plausible: chronic inflammation and foreign-body irritation are recognized promoters of malignant transformation in other contexts. For people with decades-old retained fragments, awareness of this theoretical risk is reasonable even if active surveillance specifically for it is not standard practice.

What Happens to Forensic Evidence Over Time

A retained bullet is, among other things, a piece of physical evidence. The unique markings that a gun’s barrel leaves on a bullet, the grooves and striations that forensic examiners use to match a bullet to a specific firearm, do not last forever inside a body. Experimental research has shown that in warm conditions, corrosion and biofilm formation begin within days. By the fourth day of exposure to decomposition, all of the fine microscopic striations that distinguish one firearm from another were obscured, and half of the broader rifling marks were gone. By the eighth day, even the major class characteristics were completely corroded.²¹

In living tissue the process is slower, since the body’s temperature and chemistry are more stable than a decomposing environment. But bullets recovered from living patients years after a shooting can still show significant surface changes. For investigators, the takeaway is that bullets should be recovered and examined as early as possible when forensic analysis is needed, especially in warm climates.²²

Long-Term Monitoring for People With Retained Bullets

Because symptoms of lead toxicity can appear years after the initial injury, medical guidelines generally recommend periodic blood lead level checks for anyone carrying a retained bullet, especially if the fragment is near a joint or bone, if there are multiple fragments, or if the patient is a child. Symptoms worth watching for include persistent fatigue, headaches, unexplained abdominal pain, mood changes, and a drop in cognitive sharpness. For adults, symptoms tend to appear at blood lead levels above roughly 25 micrograms per deciliter, though any level above the reference range warrants attention.²³ Pregnancy is a particularly important time for monitoring, since lead stored in bone gets released as calcium is mobilized for fetal development, potentially exposing the fetus.

If blood lead levels rise or symptoms develop, the combination of chelation therapy and surgical removal of the fragment, when the fragment is accessible, tends to bring levels down and relieve symptoms.⁵ When the bullet cannot be safely extracted, for instance when it is lodged near the spine or a major vessel, chelation alone can reduce circulating lead, though it does not eliminate the ongoing source. These patients typically need closer and more frequent monitoring for the rest of their lives.