Indian Journal of Radiology and Imaging Indian Journal of Radiology and Imaging

RADIOLOGICAL QUIZ
Year
: 2002  |  Volume : 12  |  Issue : 1  |  Page : 129--130

Radiological quiz - abdomen


KV Rajagopal, BN Lakhkar, P Mehta, T Thomas 
 India

Correspondence Address:
K V Rajagopal
India




How to cite this article:
Rajagopal K V, Lakhkar B N, Mehta P, Thomas T. Radiological quiz - abdomen.Indian J Radiol Imaging 2002;12:129-130


How to cite this URL:
Rajagopal K V, Lakhkar B N, Mehta P, Thomas T. Radiological quiz - abdomen. Indian J Radiol Imaging [serial online] 2002 [cited 2019 Aug 21 ];12:129-130
Available from: http://www.ijri.org/text.asp?2002/12/1/129/30558


Full Text

A 50 year old man presented with vague abdominal pain since 11 months. One year back, he had undergone laparotomy for removal of an abdominal mass. Plain radiograph of the abdomen was unremarkable.

 View Answer

 Radiological Diagnosis



Gossypiboma (Textiloma)

Ultrasound shows thick curvilinear hyperechoic band (large arrows) with distal acoustic shadowing (arrowhead) in the left lumbar region [Figure 1]. The internal architecture of this band showed multiple linear and amorphous hyperechoic interfaces. As there was a history of previous laparotomy and typical appearance on ultrasound, diagnosis of retained surgical sponge was made. Hypoechoic band surrounding the hyperechoic band was presumed to represent the pseudocapsule formed by the granulation tissue (small arrows).

CT shows an encapsulated hypodense mass with multiple air bubbles within it (medium sized arrows). Air bubbles were separated by septae like structures. Capsule of the mass showed enhancement (large arrow). These CT findings further confirmed the diagnosis of retained surgical sponge. Bowel loops were seen to be displaced by the mass [Figure 2]. There was evidence of focal deficiency of the capsule of the mass and the mass was seen to be in direct contact with the lumen of the adjacent jejunal loop suggestive of a fistulous communication with the bowel.

MR was performed to evaluate the imaging features of this entity. MR showed a hypointense mass on both T1 [Figure 3] and T2 [Figure 4] weighted images with multiple dark spots within it giving a spotted appearance (arrowheads). These dark spots were due to air bubbles trapped within the mass. The capsule of the mass was hypointense on T1 weighted images and hyperintense on T2 weighted images. Pseudocapsule surrounding the mass is hypointense on T1 and hyperintense on T2 weighted images (arrows).

Subsequently the patient underwent surgery. A piece of retained surgical sponge was removed and was seen surrounded by purulent material and the pseudocapsule formed by the granulation tissue. The sponge was seen eroding the adjacent jejunal wall. Segmental resection of the adjacent jejunum with end to end anastomosis was performed.

Retained surgical sponges, euphemistically called 'Gossypibomas', are rare occurrences, which are infrequently reported in the literature because of legal complications. According to Joson et al, their occurrence was estimated as 1 per 1000-1500 surgeries [1]. Their manifestations and complications are so variable that the diagnosis is difficult and patient morbidity is significant.

The retained surgical sponge in the abdominal cavity stimulates an aseptic inflammatory reaction that produces adhesion, fibrosis and encapsulation. In most instances, it causes no symptoms. Occasionally a foreign body reaction may be seen which is exudative in nature and cause abscess formation and the patient may present with fever and abdominal pain. Our patient developed abdominal pain one month after the previous operation. At surgery purulent material was noted around the retained sponge.

Radio-opaque markers are now present in surgical sponges, and their appearances have been documented. The gossypiboma still presents a diagnostic problem if the marker is distorted by folding, twisting, or disintegration over a period of time. In our country such radio-opaque sponges are not readily available. Without the radio-opaque markers, retained sponges are difficult, if not impossible to diagnose.

Ultrasound appearances of gossypiboma have been described [2],[3]. They include: an echogenic area with strong acoustic shadow due to the retained gauze; a well defined cystic mass containing distinct internal hyperechoic, wavy, striped structures; and quite nonspecific patterns with a hypoechoic mass or a complex mass [1],[2],[3]. In our case, ultrasound showed a thick curvilinear hyperechoic band with distal acoustic shadowing in the left lumbar region. The internal architecture of this band showed multiple linear and amorphous hyperechoic interfaces [Figure 1].

Previous reports of the CT findings of this lesion have described the foreign body as a round, sharply outlined mass with a dense, enhancing wall. The centre of the lesion had heterogeneous densities created by a whirl-like hypo-and hyperdense structure[3]. In our case, the CT showed a peripherally enhancing encapsulated hypodense mass with multiple air bubbles within it. The trapped air bubbles were separated septae like cotton fibres.

The described MR appearances of Gossypibomas included masses with low signal intensity on T1 and T2 weighted images, high signal on T1 and T2 weighted images [4], and heterogeneous signal intensity on a T2 weighted image on which the internal architecture suggested a retained surgical sponge [5]. In our patient, the MR showed a hypointense mass in both T1 and T2 weighted images. The internal architecture showed spotted appearance due to trapped air bubbles [Figure 3],[Figure 4].

References

1Jason RS, Chisolm A, Lubetsky HW. Retained surgical sponge simulating pancreatic mass. J Natl Med Assoc 1979; 71: 501-503
2Yamato M, Ido K, Izutsu M, et al. CT and ultrasound findings of surgically retained sponges and towels. J Comput Assist Tomogr 1987; 11: 1003-1006.
3Chau WK, Lai KH, Lo KJ. Sonographic findings of intraabdominal foreign bodies due to retained surgical gauze. Gastrointest Radiol 19844; 9:61-63.
4Kusashima S, Yamato M, Fujioka M, Ishibashi M, Kogure H, Tajima Y. MR findings of surgically retained sponges and towels: report of two cases. Radiat Med 1993; 11:98-101
5Mochizuki T, Takehara Y, Ichijo K, Nishimur T, Takahashi M, Kaneko M. Case report MR appearance of retained surgical sponge. Clin Radiol 1992; 46: 66-67.