PMC3625878_01
Abdominal Ultrasound and color Doppler scans of infra-umbilical Gossypiboma. (a) Transverse mid-abdominal ultrasonography image shows a well-marginated, ovoid mass with echogenic walls (A), a hypoechoic central cavity (B), and multiple curvilinear echogenic stripes within the cavity (C), some revealing posterior acoustic shadowing (D), and some, reverberation artifacts (E). (b) Longitudinal color Doppler scan through the same area, does not show any flow within the mass.
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F1
Ultrasound (USG) [Figures 1a and 1b], revealed a well-marginated, ovoid mass with echogenic walls [Figure 1a-A], and hypoechoic central cavity [Figure 1a-B]. Multiple curvilinear echogenic stripes were seen within the cavity [Figures 1a and b - C] some revealing posterior acoustic shadowing [Figure 1a - D] and some reverberation artifacts [Figure 1b - E]. On color Doppler, no flow was seen within the mass [Figure 1b]. 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 [Figure 1a - B]. Capsule was 4-5 mm thick, hyperdense, and showed moderate enhancement [Figure 1a-C]. Marked stranding was seen in surrounding omental fat especially in postero-inferior part with adherent small bowel loops - possibly ileal loops [Figure 1a-D]. There was dilatation of proximal loops and zone of transition at site of adherence, suggestive of partial obstruction [Figure 1a-E].
Contrast Enhanced Computed Tomography scans of the abdomen at the level of (a) umbilicus and (b) infra-umbilical region, show a well-encapsulated ovoid mass (A) with a central hypodense cavity having hyperdense whorled stripes (B). Capsule is hyperdense and shows moderate enhancement (C). Bowel loops are adherent to the mass (D) and proximal loops are dilated (E).
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F2
Computed tomography [Figures 2a and b] revealed a well-encapsulated ovoid mass in the umbilical region [Figure 2a-A], which was adherent to the anterior abdominal wall.
MRI abdomen-T2 W axial images of Case 1 at (a) infra-umbilical and (b) umbilical level show a large well-defined ovoid mass (A) in mid abdomen, adherent to small bowel loops (B). It has a thick hypointense capsule (C) and a central fluid filled core with whorled stripes of intermediate intensity (D).
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F3
Imaging (MRI) [Figures 3a and b] showed a large well-defined ovoid mass in the mid abdomen region [Figure 3a-A], adherent to anterior abdominal wall and also, to small bowel loops [Figures 3a and 3b-B]. It had a thick capsule appearing intensely hypointense on both T1-and T2-Weighted (W) images [Figure 3b-C] and a central fluid filled core with hypointense whorled stripes [Figure 3b-C].
Operative photograph shows an encapsulated mass of gauze encased in omentum adherent to bowel (A). Inset shows its cut section with gauze (B) visible inside the pseudo-tumor.
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F4
The 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 [Figure 4].
PMC3625878_02
Retained sponge causing gastrocutaneous fistula. a) shows fistulogram being performed from opening at lateral end of scar b) Fistulogram performed from opening at lateral end of scar (A) shows mottled pooling of contrast in right hypochondrium (B) and contrast in stomach (C). (c) Axial CECT image at level of pylorus and (d) coronal reconstructed image through the same area show a well-circumscribed mass with contrast admixed with spongiform mottling suggestive of foreign body, in the right sub-hepatic space (D).
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F5
A contrast study carried out from the site of pus discharge [Figure 5a - A] demonstrated mottled pooling of contrast in right hypochondrium [Figure 5b - B]. Prompt entry of contrast into the stomach indicated a gastro-cutaneous fistula [Figure 5b - C]. A well-circumscribed mass with spongiform mottled lucencies suggestive of trapped air bubbles and some oral contrast within, was seen in the right sub-hepatic space abutting the pylorus [Figure 5c and d-D].
Operative photograph shows sponge being removed from gastric cavity in sub-hepatic region (A). Inset shows the removed sponge.
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F6
There was a fistulous communication with the anterior gastric wall and the presence of the sponge in the gastric cavity [Figure 6].