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Gossypiboma: the forgotten diagnosis.


A 69-year-old woman with a surgical history of appendectomy in 2002 and open cholecystectomy in 2003 (both of which were performed in Mexico) was transferred from an outside hospital. The patient had been symptom-free until 2 months prior to her transfer, when she developed obstructive jaundice. She initially improved after percutaneous transhepatic cholangiography (PTC) with external/internal biliary drain placement, which was performed at an outside hospital. However, a few weeks later, she developed increased abdominal pain and decreased drainage from her biliary drain. After the drain was found to be working and abdominal ultrasound (US) and computed tomography (CT) revealed an abdominal mass (not shown), she was transferred to our institution for surgical evaluation.

At the time of admission to our institution, the patient complained of abdominal pain, early satiety, and recent weight loss. On physical examination, she had mildly icteric sclerae, a slightly tender palpable right upper quadrant (RUQ) mass, an external biliary drain in place, and RUQ and infraumbilical abdominal scars. Laboratory results were significant for mild anemia and abnormal liver function tests. Ultrasound from the outside hospital had reported a heterogeneous mass left of midline and inferior to the left lobe of the liver.


The patient was admitted with the possible diagnosis of biliary obstruction secondary to abdominal neoplasm. She underwent a percutaneous cholangiogram and replacement of the biliary drain. The cholangiogram did not show any extravasation but revealed mild irregularity of the mid-to-distal common bile duct with moderate stenosis possibly due to extrinsic compression (not shown). The mass displaced the stomach and the proximal small bowel. Endoscopic US and esophagogastroduodenoscopy revealed a choledochoduodenal fistula and an extragastric fluid collection with debris, consistent with abscess due to the fistula (not shown). Abdominal CT and magnetic resonance imaging (MRI) were performed.


Contrast-enhanced abdominal CT revealed a discrete, encapsulated, 7.3 ? 6.0-cm, heterogeneous, nonenhancing mass, possibly originating from the left lobe of the liver and abutting the stomach and pancreas (Figure 1). The central portion of the mass was heterogeneous, with high-density areas (40 to 50 HU) surrounded by low-density fluidlike areas (15 to 20 HU). An external biliary drain with pneumobilia was noted. The possibilities of organized hematoma or avascular mass arising from the liver were suggested.




MRI of the abdomen revealed a 7.4 ? 6.4 ??7.0-cm, well-encapsulated mass displacing the stomach inferiorly (Figure 2). It abutted the liver, the anterior abdominal wall, and the pancreas but did not appear to originate from any of these structures. On T1-weighted (T1W) images, the mass showed uniform low signal (Figure 2A). On T2-weighted (T2W) images, the mass had areas of low signal, which possibly indicated fibrosis, and areas of high signal, which were suggestive of fluid. The capsule showed low signal intensity (Figure 2B and C) on T2W imaging. No contrast was administered.


An exploratory laparotomy was performed. After taking down the omental adhesions, a mass was found in the upper abdomen. Upon incision of the mass, purulent fluid was expressed, and a laparotomy pad retained from previous surgery became visible. The pad was removed, the cavity irrigated, and a drain placed.


Retained surgical sponge


Gossypiboma (which is also known as textiloma, cottonoid, and gauzeoma) is a mass formed by a retained surgical sponge surrounded by encapsulating reactive tissue.1 It was first described in 1884 by Wilson.2 The term is derived from the Latin word gossypium, meaning "cotton," and the Kiswahili word boma, which means "place of concealment." 3 It is not possible to precisely determine the true incidence of gossypiboma because of legal and medical concerns that lead to underreporting of cases and because some patients remain asymptomatic for years.4 However, the incidence has been reported as 1 in 100 to 3000 for all surgical interventions and 1 in 1000 to 1500 for abdominal surgery. (5)

Currently, gossypibomas occur most often in developing countries, as in this case. Of the 36 articles on the subject published between 2000 and 2005, 33 cases were from countries other than the United States and most of these were from Asia; however, approximately 1500 cases of retained surgical sponge are reported each year in the United States. (6) The index of suspicion for this diagnosis is low because of the rarity of this condition and the long delay in the manifestation of symptoms. (7)

Gossypibomas are most frequently reported in the abdomen. However, they occur at other locations such as central nervous system, extremities, breast, and thorax.8 Patients with gossypiboma can remain asymptomatic for months or years.9 The symptoms are nonspecific, as in our case, and vary according to the location of the lesion, its relation with the adjacent viscera, the body's reaction to the foreign body, and the extent of bacterial contamination. (2) Symptoms of abdominal gossypiboma include pain, palpable mass, vomiting, weight loss, diarrhea, abdominal distension, ileus, tenesmus, drainage from fistula, and protrusion through the surgical wound, rectum, or bladder. (9) History of emergency surgery, unplanned change in the type of operation, and large body mass index are associated with increased risk of gossypiboma and should trigger consideration of this diagnosis. (10)

Cotton sponges, which are the most commonly reported postoperative foreign bodies, do not undergo any specific biological changes (Figure 3). Two types of foreign-body reaction can occur. (8) The first is an aseptic fibrinous response that causes granuloma formation by creating adhesions and encapsulation; and the second is an exudative response leading to abscess formation with or without bacterial infection. The body may then attempt to extrude the foreign material, leading to postsurgical complications such as pseudotumor, granulomatous peritonitis, and perforation into adjacent viscera, which may then result in intestinal obstruction or extrusion of the sponge through the rectum. (10)

Due to the nonspecific nature of the symptoms and the long latent period between surgery and manifestation of symptoms (reported to be as long as 40 years (4)), the diagnosis of gossypiboma is rarely suspected clinically, but can be suggested by imaging studies.

On radiographs, the most specific imaging findings of gossypiboma are curved or linear opacities, which represent the radiopaque markers on the surgical material (3) (Figure 4). Some radiographic features of these markers are specific to certain objects; eg, linear densities with peculiar infolding or whorled (spoke-wheel) configurations suggest a towel as the cause, and a low-attenuation mass with multiple gas bubbles suggests a sponge or foam tablets as the cause. (7) There are limitations in using radiopaque markers to diagnose gossypiboma, however. First, although surgical gauze with impregnated radiopaque markers was first introduced by Cahn in 1929, it was not generally used in the United States until roughly 1940.11 Second, surgical sponges without markers are still used in some developing countries, as happened in our case. Third, calcification of the surgical gauze may obscure the radiopaque markers. (3) Fourth, the marker may become distorted because of folding, twisting, or disintegration. For these reasons, in diagnosing gossypiboma, it is very important to use other imaging modalities, such as CT, US, MR, and even positron emission tomography (PET), and to be aware of its specific appearance with each of these modalities.

On CT, a gossypiboma may manifest as a cystic lesion, but its most specific finding (found in 54% of cases) is a spongiform pattern with entrapped gas bubbles, which slowly decrease over time. Other findings include capsular enhancement, concentric layering, calcification of the wall of the mass,8,9 and calcified reticulate rind, a sign that is formed by the gradual deposition of calcium along the fiber network of the surgical gauze.3 CT has also been used to guide needle biopsy. The contrast-enhanced abdominal CT of our patient showed an encapsulated heterogeneous mass without enhancement.

MRI findings have most often been reported as a well-defined mass with a fibrous capsule that exhibits low signal intensity on T1W imaging and high signal intensity on T2W imaging. (12) Wavy hypointensities that are sometimes seen in T2W images have been reported to be a specific feature of gossypiboma. (13) In our case, the capsule was hypointense on T1W and T2W imaging, and the mass contained areas of low and high signal.

On US, a gossypiboma appears as a well-defined hypoechoic mass containing a wavy hyperechoic area with marked acoustic shadowing, even in the absence of gas and calcification. (14) In our case, the US finding from an outside institution was reported as a heterogeneous mass. The sensitivity of US may be low in the early postoperative period because of intestinal distension, incisional pain, and the surgical wound. (4) Fused PET/CT has been used in diagnosing gossypiboma. A "rim" pattern of fluorodeoxyglucose uptake has been described as a characteristic finding, but this is not specific. (5)


Although rare, gossypiboma is a serious complication of surgery and still occurs throughout the world, including the United States. It should be considered a diagnostic possibility in any patient with prior surgery in the area of concern and with a mass seen on imaging studies. Since early diagnosis and treatment of gossypiboma significantly decrease morbidity and mortality, radiologists and surgeons should suggest gossypiboma in the appropriate settings.


(1.) Cerwenka H, Bacher H, Kornprat P, Mischinger HJ. Gossypiboma of the liver: CT, MRI and intraoperative ultrasonography findings. Dig Surg. 2005;22:311-312. .

(2.) Hyslop JW, Maull KI. Natural history of the retained surgical sponge. South Med J. 1982;75: 657-660.

(3.) Lu YY, Cheung YC, Ko SF, Ng SH. Calcified reticulate rind sign: A characteristic feature of gossypiboma on computed tomography. World J Gastroenterol. 2005;11:4927-4929.

(4.) Yildirim S, Tarim A, Nursal TZ, et al. Retained surgical sponge (gossypiboma) after intraabdominal or retroperitoneal surgery: 14 cases treated at a single center. Langenbecks Arch Surg. 2006; 391: 390-395.

(5.) Yuh-Feng T, Chin-Chu W, Cheng-Tau S, Min-Tsung T. FDG PET CT features of an intraabdominal gossypiboma. Clin Nucl Med. 2005;30: 561-563.

(6.) Pezzullo JA. Images in medicine. Gossypiboma. Med Health R I. 2004;87(5):149.

(7.) Salman M, Ahmed N, Mansoor MA. Gossypiboma in the early postoperative period: Computed tomography appearance. J Coll Physicians Surg Pak. 2005;15:435-436.

(8.) Sheehan RE, Sheppard MN, Hansell DM. Retained intrathoracic surgical swab: CT appearances. J Thorac Imaging. 2000;15:61-64.

(9.) Lauwers PR, Van Hee RH. Intraperitoneal gossypibomas: The need to count sponges. World J Surg. 2000;24:521-527.

(10.) Gawande AA, Studdert DM, Orav EJ, et al. Risk factors for retained instruments and sponges after surgery. N Engl J Med. 2003;348:229-235.

(11.) Rymer CA, McCarthy JD. A silent sponge speaks. Am J Surg. 1974;128:103-104.

(12.) Lo CP, Hsu CC, Chang TH. Gossypiboma of the leg: MR imaging characteristics. A case report. Korean J Radiol. 2003;4:191-193.

(13.) Vayre F, Richard P, Ollivier JP. Intrathoracic gossypiboma: Magnetic resonance features. Int J Cardiol. 1999;70:199-200.

(14.) Wan YL, Huang TJ, Huang DL, et al. Sonography and computed tomography of a gossypiboma and in vitro studies of sponges by ultrasound. Case report. Clin Imaging. 1992;16:256-258.

Prepared by Farshad Ostovar Sirjani, MD, Department of Internal Medicine, University of California, San Francisco, CA, and Eugenio O. Gerscovich, MD, John P. McGahan, MD, and Rebecca Stein-Wexler, MD, Department of Radiology, University of California, Davis Medical Center, Sacramento, CA.

Farshad Ostovar Sirjani, MD, Eugenio O. Gerscovich, MD, John P. McGahan, MD, and Rebecca Stein-Wexler, MD
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Author:Sirjani, Farshad Ostovar; Gerscovich, Eugenio O.; McGahan, John P.; Stein-Wexler, Rebecca
Publication:Applied Radiology
Date:Aug 1, 2008
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