Gossybipoma of the Abdomen: US and CT findings

Clinical History

Patient with fever and abdominal pain, hystory of past surgery for a sigmoid-rectal junction neoplasm and abdominal mass located in the left flank region.

Imaging Findings

The patient presented to our observation with fever and complaining acute left flank pain. The laboratory evidenced increment of ESR (120 mm/h) and marked leucocitosis (21.000/mm), signs of an important flogistic phenomenon in action. The clinical history revealed that the patient underwent an anterior rectal resection, 20 days before, for the treatment of a neoplasm of the sigmoid-rectal junction. In order to obtain further clinical data and in the attempt to evidence the cause of the pain, an abdominal ultrasound study was performed. In our case, ultrasounds showed a thick curvilinear hyperechoic band with distal acoustic shadowing in the left flank region. The internal architecture of this band showed multiple linear and amorphous hyperechoic interfaces. A following multi-slice CT was necessary to confirm the diagnostic hypothesis. Not-enhanced CT showed an encapsulated hypodense mass with multiple air bubbles within the mid-left abdominal region, that was related with the abdominal wall , the tail of the pancreas and the front face of the left kidney. Moreover, some hyperdense structures were described. After the administration of medium contrast, the mass appeared surrounded by a thickened and hypervascular wall.

Discussion

Gossypiboma is the technical term for a retained surgical sponge. It is derived from the latin "gossypium" (cotton) and the swahili "boma" (place of concealment). A synonym for this word is textiloma, which combines the word textile (until recently most surgical sponges were made of cloth) and the suffix -oma, meaning a tumor or growth. Gossypiboma are rarely documented, owing to medical, legal, and other reasons. Literature shows that foreign bodies retained in the abdominal cavity include sponges, towels, artery forceps, pieces of broken instruments or irrigation sets and rubber tubes. A surgical sponge constitutes the most frequently encountered object (69%) because of its common usage and small size. Around 50% of retained gauze pieces are discovered after at least four years of the surgery. The presentation may be acute or relatively delayed. Acute presentations generally follow a septic course with abscess and fistulas formation. Delayed presentations may follow years after original surgery, with adhesion formation and encapsulation by a granulation tissue. Eventually, it may produce various complications leading to its discovery, such as obstruction, peritonitis, adhesions, fistulas, abscess formation and erosion into gastrointestinal tract. The imaging features of retained intra- abdominal gauze piece are variable. Ultrasounds may be helpful, both in B-mode and colour-Doppler mode: a sponge typically appears as an irregular echogenic structure with strong, extensive posterior acoustic shadowing and with absence of a vascular pattern inside the lesion but only around it (granulation tissue), but usually a multi-slice CT is required. Before contrast administration there is a non-specific appearance of a mass or a complex fluid collection and differentiation from hematoma or abscess is difficult. CT scans may be useful to reveal hyper-dense markers often sited inside the gauzes: this is an important finding for the differential diagnosis. The gauze piece shows a strong rim enhancement after intravenous contrast administration: the lesions are fairly well circumscribed with a densely enhancing wall and the gas trapped in the fiber meshwork of the gauze causes a whirl-like pattern of the lesion. In conclusion, Gossypiboma is a rare finding, but literature shows that it is an important reality to evaluate in differential diagnosis, especially in patients with anamnesis of emergency surgery, abdominal or pelvic surgery and with greater body mass index (BMI). CT and US are important diagnostic instruments for the revealing of gossybipoma in these cases, allowing, sometimes, to avoid further invasive exams.

Differential Diagnosis List

Final Diagnosis

Gossypiboma

URL:	https://eurorad.org/case/3667
DOI:	10.1594/EURORAD/CASE.3667
ISSN:	1563-4086