Imaging features of gossypiboma: report of two cases.
S Prasad, A Krishnan, J Limdi, T Patankar
Department of Radiology, Seth G.S. Medical College and K.E.M. Hospital, Parel, Mumbai, India., India
Department of Radiology, Seth G.S. Medical College and K.E.M. Hospital, Parel, Mumbai, India.
Recognition of postoperatively retained foreign body referred euphemistically as gossypiboma is essential but is very often considerably delayed. Legal implications as well as confusing configuration patterns cause considerable dilemma in the accurate diagnosis. We present computed tomographic features of gossypiboma in two patients who presented with symptoms of fever and pain in the immediate post-operative period. A prospective radiological diagnosis is essential for further management in these patients.
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Prasad S, Krishnan A, Limdi J, Patankar T. Imaging features of gossypiboma: report of two cases. J Postgrad Med 1999;45:18-9
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Prasad S, Krishnan A, Limdi J, Patankar T. Imaging features of gossypiboma: report of two cases. J Postgrad Med [serial online] 1999 [cited 2022 Aug 11 ];45:18-9
Available from: https://www.jpgmonline.com/text.asp?1999/45/1/18/357
Attendant clinicians frequently encounter patients with a wide spectrum of complications in the post-operative period. A gossypiboma is a mass within the body that is composed of a cotton matrix- very commonly, an unmarked laparotomy sponge. A good understanding of the radiological appearances of this foreign body helps in appropriate early management of such patients.
A thirty-year-old woman presented with gradually progressive abdominal distension and mild fever fifteen days after a caesarean operation. At admission, she was febrile. Clinical examination revealed an ill defined, mildly tender, left lumbar swelling. Laboratory investigations showed mild leucocytosis with neutrophil predominance. Ultrasonography revealed a large, mixed echogenic mass in the left lumbar region. Computed tomographic (CT) scan demonstrated a low-density mass within the peritoneal cavity. There were multiple speckled gas bubbles within the mass [Figure:1]. A serpenginous, relatively high-density component was seen within the mass. A provisional diagnosis of a retained sponge with surrounding abscess was considered. At laparotomy, a localized abscess surrounding a surgical sponge was found. The patient made an unremarkable recovery from the operation and was subsequently discharged on the seventh day.
A twenty-two-year-old man presented with left loin pain within two days of a nephrectomy. Clinical examination and laboratory investigations as well as ultrasound examination failed to reveal any abnormality. Plain and contrast enhanced CT scan showed a low-density focus suggestive of gas in the left renal fossa. There was no evidence of any fluid collection. On interaction with the surgeons, it was found out that the operating surgeon had placed gel foam particles in the left renal bed to control intra-operative haemorrhage. The patient improved on conservative treatment.
Gossypibomas result from a variety of operative substances. Surgical sponge is the commonest reported postoperative intra-abdominal foreign body and has been widely mentioned in the literature,,,,,,. Pathologically two types of reactions are described against them. One is an aseptic fibrinous response that results in adhesion or encapsulation leading to granuloma formation. The other is an exudative type leading to abscess formation with or without bacterial super-infection. Sometimes, the gossypiboma may remain unnoticed for years till the time that they result in a complication or be incidentally picked up. They cause a bewildering array of complications. The common ones are bowel obstruction, perforation, pseudotumour,, and granulomatous peritonitis. The low index of suspicion due to the rarity of the condition and the long latency in the manifestation of the symptoms frequently result in misdiagnosis (or even missed diagnosis) leading to inordinate delay in proper management.
Radiological characteristics of gossypibomas are protean. Diagnosis is greatly guided by the details of the previous operation. However some features are peculiar to certain objects. Linear densities with peculiar infolding/whorled (spoke-wheel) configuration suggest a towel as the cause,. On the other hand sponges as well as gel foam tablets appear as low-attenuation masses with multiple gas bubbles. In both our cases evidence of gas in the lesion prompted us review the surgery and suggest a provisional diagnosis of gossypiboma
In conclusion, gossypiboma has to be considered as a strong diagnostic possibility in postoperative patients presenting with unexplained symptoms such as pain and intestinal obstruction. We believe that speckled gas within a mass at the site of surgery should strongly suggest foreign body as a possible aetiology. Early recognition of this entity will assist in prompt institution of appropriate treatment, reducing morbidity and mortality in these patients.
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