Teaching Case

Perineal fistula with purulent vaginal discharge

The patient underwent a total colectomy and ileorectal anastomosis 10 years previously for ulcerative colitis. Five years later , a persistent proctitis in the rectal stump was treated by ileoanal anastomosis (J Pouch) Unfortunately this was followed by a pouchitis and ileovaginal fistula which was successfully treated by a pouchectomy and formation of a terminal ileostomy. The patient then presented with a perineal fistula and purulent vagina discharge , fever , cachexia and weight loss of 5 Kg. A plain radiograph of the abdomen was non-specific, and the patient underwent an abdominal CT and CT fistulogram.

The term textiloma is used for a foreign body (surgical sponge) unwitting left in an operative wound. A Gossypiboma describes the inflammatory granulomatous reaction caused by such a foreign body, The reported frequency of this occurrence (between 1 in 1000 to 1 in 10,000 operations) is probably an underestimate and morbidity can be high. Gossypibomas most commonly occur following abdominal and gynaecological surgery .They often produced non specific and variable symptoms although a mass and abdominal pain are common. There can be a long interval between surgery and clinical expression of this complication particularly if the Gossypibomas remains sterile. However once infection sets in, severe complications can occur often in a matter of days .These include abscess formation, peritonitis, septicaemia, fistulation and haemorrhage and have a significant mortality (15-25%). Radiological investigation has an important part to play in diagnosis. If a radio-opaque marker is present in the sponge, then this may be detected on plain radiography which should be the first investigation. The CT appearances are not pathognomonic, but a number of features act as useful clues to the diagnosis: a well defined and heterogeneous collection, spongiform pattern with gas bubbles, calcification or the presence of the radio-opaque marker, and poor rim enhancement following intravenous enhancement. Gossypibomas can be prevented by careful scrutiny of the operative wound at the time of surgery, careful 'sponge count' during surgery and the use of radio-opaque markers in the sponges. A poor post-operative recovery with non-specific symptomatology should alert the clinician to the possible diagnosis.