Clinical History
81-year-old patient with persistent leucorrhoea and febricula. She underwent hysterectomy four months before and clinical symptoms started one week after the surgery. She has been treated with antibiotics without complete clinical improvement. The analytical findings were anodyne, with normal C-reactive protein and white blood cells. An abdominal CT examination was performed.
Imaging Findings
The non-enhanced pelvic CT showed an encapsulated hypodense mass (7.3 cm) with multiple bubbles as well as the presence of some hyperdense foci. The mass was located in the surgical bed, adjacent to the sigmoid colon that presented thickened walls. Enhanced pelvic CT showed the encapsulated hypodense mass with wall enhancement. A coronal MIP reconstruction showed a hyperdense linear material within the pelvic mass.
Discussion
Background:
Gossypiboma or textiloma are the technical terms to describe a pseudotumour of cotton matrix, usually a surgical sponge, which is left behind in the body during a surgery [1-4]. The reported frequency of this pathology is one in 1000-5000 intraabdominal surgery [2, 4].
Clinical Perspective:
A gossypiboma produces a foreign body reaction and the presentation may be acute (infection or abscess formation) or delayed (granuloma) [1, 3].
Acute reactions occur early in the postoperative period and generally follow a septic course, with abscess and even fistula formation, while delayed reactions can appear years after the surgery with adhesion formation, encapsulation and, eventually, granuloma formation [1-3].
Symptoms are usually nonspecific and may appear years after surgery. The most common findings and symptoms of textilomas are pain, palpable mass, vomiting, fever, abdominal distention, abscess and fistula formation, obstruction and even erosion into the gastrointestinal tract [1].
Imaging Perspective:
Although CT findings are not pathognomonic, CT is the preferred imaging tool to detect textilomas. The most important finding is the presence of radio-opaque/hyperdense markers that is seen as a thin metallic density. Another characteristic finding is a spongiform pattern with gas bubbles [1-4]. A well-defined and heterogeneous collection and rim enhancement after intravenous enhancement is also usually seen [1, 3, 4].
Take Home Message:
In conclusion, gossypibomas may not be easy to diagnose so awareness of their CT imaging appearance is critical to achieve the correct diagnosis.
Differential Diagnosis List
Pelvic gossypiboma
Pelvic abscess
Adnexal tumor
Divericulitis
Intestinal obstruction
