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Case 5

                                       Contributors

                                                Dr. Santosh Dasar

                                                Dr. Arpita S                                                    

 Diagnosis
 Intra-abdominal Gossypiboma

 Radiological Findings, Disease course, and Management

 

 CT

   NCCT                     Arterial phase                Venous phase

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Findings

  • Well-defined lobulated spongiform intra-peritoneal mass in the infraumbilical region with thin peripheral serpigenous hyperdenisties (calcification / oral contrast).

  • Presence of multiple gas bubbles within with non-enhancing hypodense stripes abutting the anterior abdominal wall.

  • measures 10.6 (CC) x  10.4 cm (ML) X 7.7 cm( AP).

  • Multiple adherent small bowel loops seen along the periphery with adjacent mesenteric fat stranding with few adherent bowel loops showing spiculations.

  • No evidence of dilatation of proximal small bowel loops.

  • Mildly enlarged liver (17.4 cm),normal in shape and enhancement pattern showing mild diffuse fatty infiltration in the left lobe.

Impression

  • Well-defined spongiform intra-peritoneal mass in the infraumbilical region with thin peripheral serpegenious calcification and  adherent small bowel loops as described above……suggestive of calcified gossypibioma. Possibility of neoplastic etiology less likely.

  • Mild hepatomegaly with fatty infiltration in left lobe.

  • Multiple enlarged mesenteric lymphadenopathy.

Disease course, and Management

Laparotomy with resection and anastamosis for intestinal obstruction was performed 

 

Operative findings:

  • fistula formed between 2 loops of small bowel i.e jejunum and ileum. On opening the fistula, a hard foreign body was detected made up of fabric/cloth

  • no external fistula found

  • no proximal or distal bowel perforation/adhesions seen.

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Discussion

   Background

  • Gossypiboma describes a mass of cotton matrix that is left behind in a body cavity during an operation. The term “gossypiboma” is derived from the Latin word gossypium, meaning cotton, and the Swahili word boma, meaning place of concealment

  • most frequently diagnosed in the intraabdominal cavity. However, they can also be found in the chest, extremities, CNS, and breast

  • Delays in diagnosis could increase mortality and morbidity 

  • may present at any time, from immediately postoperatively to several decades after initial surgery

  • can cause foreign body reactions

  • can cause infection or abscess formation in the early stage, whereas others remain clinically silent for many years

  • cause two types of responses in the body: exudative and aseptic fibrous 

    Aseptic fibrous- adhesions, encapsulation, and eventually, granuloma         formation

    Exudative- usually occurs early in the postoperative period

                 may involve secondary bacterial contamination, which results                  in various fistulas  

   The longer the retention time, the higher the risk of fistulization 

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 Diagnosis

  • Diagnosis may be difficult because it may mimic a benign or malignant soft-tissue tumor in the abdomen and pelvis  

  • may present as an intraabdominal mass and lead to erroneous biopsy attempts and unnecessary manipulations

  • Clinical presentation may be acute or subacute. Patients can present with nonspecific abdominal pain and intestinal obstruction, a palpable mass, nausea, vomiting, abdominal distension, and pain

 

Imaging findings

 Radiography

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  • most commonly used method

  • If the sponge contains a radiopaque marker, the diagnosis can be made easily on conventional radiography

  • characteristic whorllike pattern may be present

  • may reveal a fine opacity and some mottled small air densities superimposed on this area

  • In cases complicated by fistula formation, administration of radiographic contrast material may help define the anatomy and extent of the abnormality


 Ultrasound

  • usually a well-delineated mass containing a wavy internal echo with a hypoechoic ring and strong posterior acoustic shadowing

  • can be classified into two groups, a cystic type and a solid type

    cystic- cystic lesion with a zigzag echogenic bundle

    solid- complex mass containing hyper- and hypoechoic regions  

  • Acoustic shadowing on ultrasound is usually caused by the retained material itself, calcified regions in the gossypiboma, or pockets of air 

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CT

  • low-density heterogeneous mass with an external high-density wall that is further highlighted on contrast-enhanced imaging and that has a spongiform pattern containing air bubbles 

  • radiopaque marker strip is seen as a thin metallic density in the mass

  • calcification of the mass wall may be observed on CT 

  • spongiform pattern with gas bubbles is the most characteristic CT sign for gossypibomas

  • mass may contain wavy striped high-density areas that represent the sponge itself 

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 MRI
  • ​​the signal intensity may vary according to histologic composition, stage, and fluid content of the tumor
  • Retained absorbable hemostatic sponges can be seen as intermediate T1 and high or complex mixed (similar to the whorled appearance of other retained surgical sponges) T2 signal intensity
  • In general, most lesions caused by foreign bodies are hypointense on T1-weighted images and hyperintense on T2-weighted images
 
 Differential diagnosis

 Abdominal gossypiboma

  • Abscess: may be indistinguishable from those of an intraabdominal abscess on CT

  • Intestinal obstruction: should be considered in the differential diagnosis of acute mechanical intestinal obstruction in patients who previously underwent laparotomy


 

 Treatment and prognosis of intra-abdominal gossypiboma

  • The best treatment is surgical exploration.

  • However, surgical intervention may not always be required. Spontaneous migration can occur, leading to expulsion of the foreign material through the anus during defaecation

 Conclusion

  • Diagnosis is not often easy

  • Delayed diagnosis can be problematic

  • Awareness of the typical radiologic appearances is critical to the diagnosis of retained surgical sponges or swabs

  • retained sponges are often clinically unsuspected and may be first recognized on imaging.

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References

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