Abdominal gossypiboma: A pictorial review
Poster No.:
C-395
Congress:
ECR 2009
Type:
Educational Exhibit
Topic:
Abdominal and Gastrointestinal
Authors:
A. Canelas, M. Seco, B. Graça, F. Cavalheiro, L. Curvo-Semedo,
L. Teixeira, F. Caseiro-Alves; Coimbra/PT
Keywords:
Gossypiboma
DOI:
10.1594/ecr2009/C-395
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Learning objectives
To describe the clinical and radiologic spectrum of abdominal and pelvic gossypibomas.
Background
Introdution
The term gossypiboma is used to describe a mass within the body that is composed of
cotton matrix and most commonly refers to 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. These
retained sponges were first referred to as "textilomas", but were renamed "gossypiboma"
in 1978. The first case was reported by Wilson in 1884.
Gossypibomas may present at any time, from immediately postoperatively to several
decades after initial surgery. Around 50% are discovered after at least four years of the
surgery.
Detection of the radiopaque markers incorporated into the sponge and the meticulous
'sponge counts' in the operating room are not foolproof, with studies showing a 10% falsenegative rate.
Pathophysiological Aspects
Pathologically two types of reactions are described against gossypibomas.
One is an exudative type leading to abscess formation with or without bacterial superinfection. This type of reaction may present in the immediate post-operative period and
simulate abscess or haematoma.
The other is an aseptic fibrinous response around the retained sponge that results
in adhesion or encapsulation and eventually in the development of a foreign-body
granuloma. This type of reaction does not usually present any clinical symptoms although
a palpable mass may be felt.
Sometimes, the gossypiboma may remain unnoticed for years till the time that they result
in a complication or be incidentally picked up. During the period that the gossypiboma
remains in the body extrusion of the gauze can occur externally through a fistulous tract
or internally into the rectum, vagina, bladder or intestinal lumen. By either fistulizing to
a lumen or through direct migration, it can cause intestinal obstruction, malabsortion,
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and gastrointestinal hemorrhage. 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.
The longer the retention time, the higher is the fistulization risk.
Clinical Manifestations
Symptoms of gossypibomas are variable and can be exhibited for several years or even
for decades after surgery. Patients can present with nonspecific abdominal pain, nausea,
vomiting, abdominal distension, intestinal obstruction and a palpable mass.
Acute presentations generally follow a septic course with abscess and granulomatous
and fistula formation. The differential diagnosis in such cases includes post-operative
collection, hematoma, and non-foreign body abscess.
Delayed presentation may follow years after original surgery, with adhesion formation and
encapsulation by a granulation tissue, and the lesion may present as a mass or subacute
intestinal obstruction. In these cases, the differential diagnosis typically includes tumor.
Eventually, it may produce various complications leading to its discovery, such as
peritonitis, fistulas and erosion into the gastrointestinal tract.
The only remedy for clinical symptoms associated with gossypiboma is surgical removal
of the mass. If the gossypiboma remains asymptomatic, the therapeutic approach must
balance the potential risk of evolution of the foreign body and the risk of surgical removal.
The clinical history can help to differentiate these 2 alternatives because the onset of
complaints is usually much earlier in patients with postoperative scar formation compared
with those with gossypiboma. However, although all patients presented with newly
developed symptoms at the site of the mass, just because the gossypiboma is there does
not necessarily mean that it is the cause of the patient's new symptoms. The careful
clinical evaluation for the cause of the symptoms is needed.
Differential Diagnosis
The differential diagnosis of gossypiboma includes faecaloma, hematoma, abscess
formation and tumour.
Faecaloma may have a spotted appearance on CT but has a recognizable colonic wall
and lacks thick well-defined capsule.
Hematoma is seen in the early postoperative period and shows resorption in the following
examination.
Abscess is visualized as a mass of fluid density and a well-defined enhancing wall with
a wavy, striped, or spotted internal high-density areas within the mass.
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Gossypiboma mimicking tumour is usually seen a palpable abdominal mass in a patient
who is asymptomatic or has nonspecific abdominal complaints with a past history of
laparotomy. This condition must be kept in mind for correct diagnosis to be made.
Prevention
Gossypibomas can be prevented by careful scrutiny of the operative wound at the
time of surgery, meticulous count of materials sponge during surgery and the use of
radio-opaque markers in the sponges. A poor postoperative recovery with non-specific
symptomatology should alert the clinician to the possible diagnosis. Most reported cases
of gossypibomas occur in the presence of a normal pack count.
Imaging findings OR Procedure details
Gossypibomas typically have an inconsistent radiologic appearance, which depends on
the amount of time that the foreign body has been in situ, the type of material, and
the anatomic location. Although certain characteristic features of gossypiboma have
been described on plain-films, CT, ultrasound and even magnetic resonance the imaging
features of retained sponges may be variable with any technique, and the diagnosis can
be especially difficult if a radiopaque marker is not present.
Radiography
In most countries, surgical sponges contain radiopaque material that facilitates detection
by standard abdominal radiography (Fig. 1 and 2). Such sponges can also be identified
readily in CT images. However, surgical sponges without radiopaque markers are still
used in many institutions, and this type of sponge is very difficult to identify by using
standard radiographic and CT imaging. Therefore, retained surgical foreign bodies often
make diagnosis intractable.
The typical appearance of gossypiboma often includes a whirllike pattern of radiopaque
thread on radiographs. This finding may be due to gas of an intestinal origin trapped
between the fibers of the sponges. However, this finding is not always present. The
diagnosis is easily made by plain abdominal radiography, when a radiopaque marker is
seen (Fig. 3 and 4). However, this imaging method is not helpful when these markers
are disintegrated or fragmented over time. In cases complicated by fistula formation,
radiographic contrast material instillation may be helpful to define the anatomy and extent
of the abnormality.
Ultrasound
Ultrasound may be useful, but often non-diagnostic in the diagnosis of abdominal retained
gauze.
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The ultrasound features of abdominal gossypiboma are divided into three types: an
echogenic area with intense posterior shadow (Fig. 5 - A and B), a well-defined cystic
mass containing distinct internal hyperechogenic wavy, striped structures, and nonspecific pattern with a hypoechogenic mass or a complex mass (Fig. 6 - A and B).
Acoustic shadowing is observed in all cases. This is due to the attenuation of beam by
foreign body as well as presence of gas and sometimes calcification.
Computed Tomography
Computed tomography (CT) is the method of choice for detecting gossypibomas and
possible complications. The reported CT appearances of gossypiboma are often not
pathognomonic and most of the times they are nonspecific.
The CT findings of gossypiboma are described as well circumscribed masses with a thick
wall, with or without gas, calcification or enhancement of the wall after administration of
contrast medium (Fig. 7 - A, B, C and D). The internal structure may appear whirllike or
spongiform due to the presence of gas trapped within the mesh of sponges. It may be
low density or complex with both low density and wavy, striped or spotted high density
areas that represent the sponge itself (Fig. 8 - A, B, C and D).
The spongiform pattern is characteristic but rare (Fig. 9 - A, B, C, D, E and F and Fig.
10 - A, B, C, D, E and F).
CT findings of gossypiboma, particularly in long standing cases, may be indistinguishable
from intraabdominal abscess, since air bubbles and calcification of the cavity wall as well
as contrast enhancement of the rim may be seen in both conditions.
As with conventional radiography, a hyperdense marker is not a reliable sign (Fig. 11 A, B, C and D).
Magnetic Resonance Imaging
There are few reports in which the magnetic resonance imaging (MRI) features of
gossypiboma have been described, but these lesions appear to have a variable MR signal
intensity that depends on the amount of fluid and protein associated with the lesion.
On MR imaging, a gossypiboma is typically seen as a soft-tissue density mass with a thick
well- circumscribed mass and as a whorled internal configuration on T2-weighted imaging
(T2WI). Most lesions are hypointense on T1-weighted images(T1WI) and hyperintense
on T2WI. The capsule is typically dark on T1- and T2WI. The whorled stripes within the
central portion were characteristically shown as low signal on T2WI which represented
gauze fibers.
MR images can be difficult to interpret because radiopaque filaments contains very few
free protons and, therefore, does not provide a strong MR signal intensity.
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Images for this section:
Fig. 1: Photograph of surgical sponge that interwoven radiopaque marker (arrow) is
visible.
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Fig. 2: Radiograph of surgical sponge shown in Fig. 1 reveals that the body of sponge
isn't radiopaque, but marker (arrow) is easily seen.
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Fig. 3: Abdominal radiograph. Radiopaque marker (circle) of laparotomy sponge is visible
in left middle quadrant.
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Fig. 4: Abdominal radiograph. Radiopaque marker (circle) of laparotomy sponge is visible
in left lower quadrant.
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Fig. 5: Transverse ultrasound of left lower abdomen shows an echogenic area with strong
and extensive acoustic shadowing.
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Fig. 6: Transverse ultrasound of left lower abdomen shows an echogenic area with strong
and extensive acoustic shadowing.
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Fig. 7: Transverse ultrasound of lower abdomen shows a complex mass with hyper- and
hypoechogenic regions.
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Fig. 8: Transverse ultrasound of lower abdomen shows a complex mass with hyper- and
hypoechogenic regions.
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Fig. 9: Non-enhanced CT scan of the abdomen demonstrates the radiopaque marker
(arrow) of the surgical sponge with a surrounding abscess.
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Fig. 10: Non-enhanced CT scan of the abdomen demonstrates the radiopaque marker
(arrow) of the surgical sponge with a surrounding abscess.
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Fig. 11: Contrast enhanced CT scan of the abdomen demonstrates the radiopaque
marker (arrow) of the surgical sponge with a surrounding abscess, which shows
enhancement of the wall after administration of contrast medium.
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Fig. 12: Contrast enhanced CT scan of the abdomen demonstrates the radiopaque
marker of the surgical sponge with a surrounding abscess, which shows enhancement
of the wall after administration of contrast medium.
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Fig. 13: Non-enhanced CT scan of the abdomen demonstrates a low density mass with
wavy and striped high density areas that represent the radiopaque marker (arrow).
Page 18 of 41
Fig. 14: Non-enhanced CT scan of the abdomen demonstrates a low density mass with
wavy and striped high density areas that represent the radiopaque marker (arrow).
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Fig. 15: Contrast enhanced CT scan of the abdomen demonstrates a low density mass
with wavy and striped high density areas that represent the radiopaque marker (arrow).
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Fig. 16: Contrast enhanced CT scan of the abdomen demonstrates a low density mass
with wavy and striped high density areas that represent the radiopaque marker (arrow).
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Fig. 17: Non-enhanced CT scan of the abdomen demonstrates in the left pararenal
space a thick-walled, well-encapsulated mass containing mixed high and low-attenuation
contents with gas bubbles in the centre, having the so-called spongiform appearance
(arrow).
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Fig. 18: Non-enhanced CT scan of the abdomen demonstrates in the left pararenal
space a thick-walled, well-encapsulated mass containing mixed high and low-attenuation
contents with gas bubbles in the centre, having the so-called spongiform appearance
(arrow).
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Fig. 19: Contrast enhanced CT scan of the abdomen demonstrates in the left pararenal
space a thick-walled, well-encapsulated mass containing mixed high and low-attenuation
contents with gas bubbles in the centre, having the so-called spongiform appearance
(arrow).
Page 24 of 41
Fig. 20: Contrast enhanced CT scan of the abdomen demonstrates in the left pararenal
space a thick-walled, well-encapsulated mass containing mixed high and low-attenuation
contents with gas bubbles in the centre, having the so-called spongiform appearance
(arrow).
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Fig. 21: Sagital reformation of the abdomen demonstrates in the left pararenal space
a thick-walled, well-encapsulated mass containing mixed high- and low-attenuation
contents with gas bubbles in the centre, having the so-called spongiform appearance
(arrow).
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Fig. 22
Page 27 of 41
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Fig. 23: Scout radiograph of the abdomen. Radiopaque marker (circle) of laparotomy
sponge is visible in left lower abdomen.
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Fig. 24: Sagital reformation of the abdomen demonstrates the in left lower abdomen a
thick-walled mass, containing mixed high- and low-attenuation contents with gas bubbles
in the centre (spongiform appearance).
Fig. 25: Contrast enhanced CT scan of the abdomen demonstrates the in left lower
abdomen a thick-walled mass, containing mixed high- and low-attenuation contents with
gas bubbles in the centre (spongiform appearance). There is enhancement of the wall
after administration of contrast medium.
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Fig. 26: Contrast enhanced CT scan of the abdomen demonstrates the in left lower
abdomen a thick-walled mass, containing mixed high- and low-attenuation contents with
gas bubbles in the centre (spongiform appearance). There is enhancement of the wall
after administration of contrast medium.
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Fig. 27: Contrast enhanced CT scan of the abdomen demonstrates the in left lower
abdomen a thick-walled mass, containing mixed high- and low-attenuation contents with
gas bubbles in the centre (spongiform appearance). There is enhancement of the wall
after administration of contrast medium.
Page 33 of 41
Fig. 28: Contrast enhanced CT scan of the abdomen demonstrates the in left lower
abdomen a thick-walled mass, containing mixed high- and low-attenuation contents with
gas bubbles in the centre (spongiform appearance). There is enhancement of the wall
after administration of contrast medium.
Page 34 of 41
Fig. 29: Non-enhanced CT scan of the abdomen demonstrates a large abdominal mass
containing mixed high- and low-attenuation contents. No radiopaque marker is seen.
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Fig. 30: Contrast enhanced CT scan of the abdomen demonstrates a large abdominal
mass containing mixed high- and low-attenuation contents. No radiopaque marker is
seen.
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Fig. 31: Coronal reformation of the abdomen demonstrates a large abdominal mass
containing mixed high and low-attenuation contents. No radiopaque marker is seen.
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Fig. 32: Sagital reformation of the abdomen demonstrates a large abdominal mass
containing mixed high and low-attenuation contents. No radiopaque marker is seen.
Page 38 of 41
Conclusion
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. Awareness of the typical radiologic appearances is critical to the diagnosis
of retained surgical sponges or swabs. A high index of suspicion is required because
a history of an incorrect sponge count is frequently lacking and because a radiopaque
marker is not always visible. Early recognition of this entity will assist in prompt institution
of appropriate treatment, reducing morbidity and mortality in these patients.
Personal Information
Andrea Canelas
Hospitais da Universidade de Coimbra
Coimbra - Portugal
[email protected]
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