Volume 8, Issue 2 , Pages e13-e14, February 2010
A Case of Recurrent Abdominal Pain Due to a Gossypiboma With Spontaneous Resolution
Article Outline
Although gossypiboma is an old term, many physicians are not familiar with it. Retained surgical sponge has been referred to as a gossypiboma, which is derived from gossypium (Latin, cotton) and boma (Swahili, place of concealment).
Retained foreign bodies after surgery can be life-threatening,1, 2 and they frequently result in surgical reinterventions.3, 4 The incidence of this event has been reported to be 0.03%1; however, it is estimated to occur in more than 0.1% of all laparotomies.5 The incidence in the United States has been estimated to be 1500 cases per year.6 The interval between surgery and diagnosis of a gossypiboma varies from 10 weeks to 35 years, with a mean interval of 93.5 months.7
We report a case of a 27-year-old Hispanic woman who presented with 6 months of recurrent right upper quadrant pain that worsened during 2–3 days before presentation and was associated with fever, nausea, and vomiting. Medical history was remarkable for cholecystectomy 6 months earlier in an outside hospital that was initially laparoscopic but had to be converted to conventional cholecystectomy. She had repeated visits to the emergency department and was told that her symptoms were related to surgery. On examination, she was afebrile, with tenderness to palpation of the right upper quadrant and mid-epigatric areas. Laboratory data revealed a mild leukocytosis but were otherwise normal. Computed tomography scan of the abdomen showed a small amount of air in the wall of the duodenum adjacent to the gallbladder fossa consistent with microperforation and a radiolucent foreign body in the small bowel (Figure A). The patient was admitted and observed. After 2 days, the right upper quadrant pain improved, but she developed left lower quadrant pain. Repeat imaging showed migration of the foreign body to the left lower quadrant (Figure B). Later that day the patient passed a 12-inch by 12-inch lap sponge per rectum (Figure C). The patient's symptoms completely resolved, and she was discharged.
Our case demonstrates an unusual case of gossypiboma that migrated through the duodenum and passed with the stool. Many risk factors have been described for this event, and in our patient we can identify the change of the planned operation procedure as one of them.8 This entity is rarely documented in the US, which might be related to the improved surgical procedure or legal reasons; nevertheless, it is important to consider gossypiboma in patients with similar complaints who had recent abdominal procedures.
The presentation of a gossypiboma can also vary. It can present acutely with a sepsis-like picture, or it can be manifested as chronic complaints like abdominal pain, as in our patient. Complications that have been reported include obstruction, peritonitis, adhesions, fistulas, abscess, and erosions into the gastrointestinal tract.
Penetration of surgical sponge into the bowel lumen and its spontaneous passage with the stools are rare, but they have been reported even up to 5 years after surgery.9 The mechanism for this event has been proposed to be initiated by an inflammatory response and abscess pocket formation around the sponge between the abdominal wall and the intestine. This event would result in the perforation of the intestine and posterior migration of the sponge into the bowel lumen. Then the peristaltic action of the intestine would draw the sponge into its final intraluminal location.10
References
- Surgical gauze pseudotumor. Am J Surg. 1988;155:235–237
- . The reasons for leaving foreign bodies in the abdominal cavity and the prevention of this complication. Vestn Khir Im I I Grek. 1988;157:79–84
- . The risk of an unplanned return to the operating room in Australian hospitals. Aust N Z J Surg. 1996;66:10–13
- . Medical malpractice related to foreign bodies left behind during surgical procedures. Acta Med Leg Soc. 1982;32:317–320
- . Foreign bodies in the heart. Medicina. 2002;38:304–311
- . Foreign bodies and intraperitoneal post-operative adhesions. J Long Term Eff Med Implants. 1997;7:235–242
- . Transmural migration of retained surgical sponges: a systematic review. Obstet Gynecol Surv. 2008;63:465–471
- Risk factors for retained instruments and sponges after surgery. N Engl J Med. 2003;348:229–235
- Transgastric migration of a surgical sponge. J Clin Gastroenterol. 1997;24:55–57
- . Complete intraluminal migration of a retained surgical lap sponge 4 years after appendicectomy: a case report. Eur Surg. 2005;57:321–324
Conflicts of interest The authors disclose no conflicts.
PII: S1542-3565(09)00833-7
doi:10.1016/j.cgh.2009.08.029
© 2010 AGA Institute. Published by Elsevier Inc. All rights reserved.
Volume 8, Issue 2 , Pages e13-e14, February 2010
