Presentation
Two weeks post-cesarian section complaining of gradual onset and progressive course of abdominal distention, nausea, vomiting, and lower abdominal pain.
Patient Data
Small bowel dilatation with fecalization proximal to a transitional zone adjacent to an extraluminal well defined irregularly shaped thick and hyperdense-walled heterogenous mainly hypodense (of fluid density) lesion with scattered foci of air-density and an internal multi-curved linear/stripe-like metallic density.
Thick-walled fluid-dense collection between a transverse surgical scar at the lower anterior abdominal wall and the recent pregnancy-compatible bulky uterus.
On post-contrast phases, the heterogeneous lesion and the fluid collection shows only wall enhancement, and the small bowel's transitional zone didn't change.
A variable fecal and gas-containing colon down to the rectum.
Case Discussion
- A small bowel dilatation with content-fecalization proximal to a transitional zone (that didn't change in consecutive study phases denoting that it is likely not a peristaltic constriction) adjacent to an extraluminal lesion suggests an extraluminal mechanical small bowel obstruction, associated with variable fecal and gas-containing colon down to the rectum that is in keeping with proximal bowel obstruction sparing the large bowel.
- Multi-curved linear/stripe-like metallic density with some streak artifacts (that could result from a metallic or concentrated radio-opaque contrast material) mainly represents a foreign hyper-dense material (which could be a metallic instrument or the radio-opaque stripe that's usually textured-in the surgical gauze) and, along with its presence within the heterogeneous sponge-shaped density lesion (well defined irregularly shaped thick and hyperdense-walled heterogeneous mainly hypo-dense (of fluid density) lesion with scattered foci of air-density), and a recent surgery followed by the presenting clinical features are all suggestive of a gossypiboma, a surgically [iatrogenically] missed intra-abdominal surgical texture (e.g. gauze or cotton).
- A thick-wall enhanced lesion containing fluid-dense collection between a transverse surgical scar (of a recent cesarian section) at the lower anterior abdominal wall and the recent pregnancy-compatible bulky uterus is likely representing a surgical abscess.
In summary, features are suggestive of gossypiboma causing extraluminal mechanical small bowel obstruction, along with an abscess at the surgical site, mandating surgical treatment. This was performed confirming a missed surgical gauze within infection collection, and a surgical abscess. The small bowel obstruction was resolved after the gossypiboma removal.