Gossypiboma and small bowel obstruction

Case contributed by Dr Ibrahim M. Jubarah

Diagnosis certain

Presentation

Two weeks post-cesarian section complaining of gradual onset and progressive course of abdominal distention, nausea, vomiting, and lower abdominal pain.

Patient Data

Age: 35 years

Gender: Female

From the case: Gossypiboma and small bowel obstruction

Loading images...

Axial non-contrast

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 artefacts (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 gooses) and, along with its presence within the heterogeneous sponge-shaped density lesion (well defined irregularly shaped thick and hyper-dense-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., goose 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 (with or without a metallic foreign body) causing extraluminal mechanical small bowel obstruction, along with an abscess at the surgical site, mandating multiple management milestones including surgical treatment. This was performed confirming a missed surgical goose (without metallic foreign body) within infection collection, a surgical abscess, and regressed small bowel obstruction after the gossypiboma removal.