Gossypiboma, Varied Presentations: A Report of Two Cases
A 55-year-old female presented with a history of abdominal hysterectomy for fibroids, performed 13 years back. Post-operation, the patient had recurrent episodes of colicky abdominal pain and fever, without any features of obstruction. These symptoms were relieved by antibiotics. Patient also noticed a lump in her abdomen, which was migratory and remained unchanged in size over a decade. However, during the last couple of years, the lump became fixed in her lower abdomen.\nAt the time of the current admission the patient complained of severe colicky pain, vomiting, and constipation. Her abdominal examination revealed a 12 cm × 10 cm size well-defined, firm, non-tender, smooth, and fixed intra-abdominal lump in the right iliac fossa. There was no free fluid. Examination of other systems was essentially non-contributory. She was subsequently investigated and found to be a diabetic. Her other hematological and bio-chemical parameters were within normal limits. Her abdominal X-ray revealed an ovoid opacity, with density of soft-tissue, in the lower central abdomen along with displacement of bowel loops. There was no evidence of any radio-opaque marker. Ultrasound (USG) [Figures and ], revealed a well-marginated, ovoid mass with echogenic walls [–A], and hypoechoic central cavity [–B]. Multiple curvilinear echogenic stripes were seen within the cavity [Figures and - C] some revealing posterior acoustic shadowing [ - D] and some reverberation artifacts [ - E]. On color Doppler, no flow was seen within the mass [].\nComputed tomography [Figures and ] revealed a well-encapsulated ovoid mass in the umbilical region [-A], which was adherent to the anterior abdominal wall. It had a central cavity filled with contents showing inhomogeneous density i.e., hypodense areas interspersed with hyperdense whorled stripes, which showed no enhancement or calcification [ - B]. Capsule was 4-5 mm thick, hyperdense, and showed moderate enhancement [-C]. Marked stranding was seen in surrounding omental fat especially in postero-inferior part with adherent small bowel loops - possibly ileal loops [-D]. There was dilatation of proximal loops and zone of transition at site of adherence, suggestive of partial obstruction [-E].\nMagnetic Resonance Imaging (MRI) [Figures and ] showed a large well-defined ovoid mass in the mid abdomen region [-A], adherent to anterior abdominal wall and also, to small bowel loops [Figures and -B]. It had a thick capsule appearing intensely hypointense on both T1-and T2-Weighted (W) images [-C] and a central fluid filled core with hypointense whorled stripes [-C]. Fluid was hyperintense to muscles in both T1-and T2 W images. All these findings were suggestive of a possibility of gossypiboma.\nThe patient underwent exploratory laparotomy, which revealed roll gauze wrapped in thick omental cover forming a pseudo-capsule all around, with dense adhesions to surrounding small bowel []. Adhesionolysis was done and the gauze piece removed. The patient tolerated the surgery well and had no recurrence of symptoms.