Unusual presentation of abdominal mass, think gossypiboma!

Clinical History

38-year-old lady, presented with large lower abdominal solid mass and discomfort. The patient was fit and no menstrual changes. She had four previous surgeries abroad. Two Caesarean sections, open sterilisation and reversal of the sterilisation. The last surgery was four years prior to presentation. Tumour markers were normal.

Imaging Findings

Abdominal radiograph did not reveal any significant finding. Abdominal ultrasound showed the mass to be a complex cyst with both solid and fluid components, suggestive of a dermoid cyst. Then, abdominal MRI was performed and showed a complex cyst measuring 17x17 cm causing right-sided hydronephrosis. There was no internal enhancement after contrast administration and torted ovarian cyst was considered a possibility. Further discussion in the local multidisciplinary team (MDT) meeting was advised. The outcome of the meeting was to perform a laparotomy and oopherectomy.
At surgery, a large mass was found adherent to the small intestine, mesentery and abdominal wall but free from right ovary and uterus with no free fluid in the pelvis. The resected specimen was a gossypiboma related to the previous surgical gauze.

Discussion

Background:
Gossypiboma is also known as textiloma. The term gossypiboma is derived from a Latin and Swahili words - ‘gossypium’ for ‘cotton’ and ‘boma' for ‘place for concealment’. Gossypiboma is a rare but important clinical condition, it is sometimes referred to as ‘retained foreign body’ [1]. This condition occurs as a post-surgical complication which brings with it serious medico-legal ramifications. It is one of the three surgical ‘never-events’, the other two being wrong site surgery and wrong implant [2, 3, 6]. According to the Report of NHS England Never Events Task force published in February 2014, there were 130 cases of retained foreign object after surgery, reported to Strategic Health Authorities, during 2012-2013 [6].

Clinical Perspective:
Patients usually present with nonspecific symptoms several years after surgery. The condition is usually diagnosed by imaging following high clinical suspicion [2, 3].

Imaging Perspective:
If the retained foreign body contains a radio-opaque material, it could be possibly diagnosed with a plain radiograph due to ‘banded’ or ‘curved lines’ [4]. However, if there is no radio-opaque material, it becomes very difficult to diagnose with just plain radiographs. Ultrasound examinations could show findings of an echogenic areas with hypo-echoic border and posterior acoustic shadow, due to the retained foreign body within the mass [1, 4]. Computed Tomography (CT) examinations may show a well-defined mass with characteristic ‘whorled’ or a ‘spongiform’ pattern due to gas within the surgical sponge. Calcification within the mass may be seen [4, 5]. Magnetic Resonance Imaging (MRI) commonly shows low signal intensity on T1 images indicative of the retained foreign body with variable intensity of fluid within the mass [1, 2]. T2 weighted images show high signal intensity for central fluid within the mass. Contrast MRI could show outer border enhancement [2, 5]. MRI images are very helpful in diagnosing gossypiboma when the retained material is non-radio-opaque.

Outcome:
The operation was done, a large mass was found adherent to the mesentery of the small bowel and the abdominal wall. However, the right ovary was clear and there was no free pelvic fluid. The surgeon removed the mass with the appendix and part of the small bowel which was sent for histopathological assessment. The examination revealed encysted gauze pack with adherent small bowel and appendix, leading to the diagnosis of ‘gossypiboma’.

Differential Diagnosis List

Final Diagnosis

Gossypiboma

URL:	https://www.eurorad.org/case/11929
DOI:	10.1594/EURORAD/CASE.11929
ISSN:	1563-4086