An Unusual Cause of Intestinal Obstruction in a Young Female

Abstract

Question: A 30-year-old woman presented with abdominal pain and distension for 1 month. There were several episodes of vomiting over the last 2 weeks. There was history of open cholecystectomy for gallstone disease 3 years back. There was no other significant past medical or family history. On examination, there was no pallor or icterus. Abdominal examination revealed abdominal distension with mild tenderness in the epigastrium. The rest of the systemic examination was unremarkable. Routine biochemical and hematologic investigations were unremarkable. A diagnosis of subacute intestinal obstruction was considered. Abdominal radiograph in erect position showed dilatation of small bowel with multiple air–fluid levels (Figure A, arrows). Ultrasonography confirmed the dilatation of small bowel loops. There was no ascites. Noncontrast axial CT of the abdomen revealed dilatation of small bowel with air–fluid levels (Figure B, short arrow) and a hyperdense intraluminal lesion showed mottled air (Figure B, arrow). Contrast-enhanced coronal reformatted image localised the intraluminal abnormality within the ileum (Figure C, arrow). The involved segment of bowel showed mild mural thickening and adjacent mesenteric fat stranding. The proximal small bowel was dilated (Figure C, short arrow). What is your diagnosis? See the Gastroenterology web site (www.gastrojournal.org) for more information on submitting your favorite image to Clinical Challenges and Images in GI. Gossypiboma denotes a mass of cotton sponge that is accidentally retained in the body after an operation. There are 2 usual pathological responses to retained sponge: exudative inflammatory reaction leading to abscess and aseptic/fibrotic reaction leading to a mass.1Dhillon J.S. Park A. Transmural migration of a retained laparotomy sponge.Am Surg. 2002; 68: 603-605PubMed Google Scholar Transmural migration is extremely rare. Such a migration has been reported into the intestinal lumen, urinary bladder, or thorax.1Dhillon J.S. Park A. Transmural migration of a retained laparotomy sponge.Am Surg. 2002; 68: 603-605PubMed Google Scholar Intestinal transmural migration occurs in various intraabdominal locations. It results from inflammation in the intestinal wall progressing to necrosis. After complete migration of sponge, the intestinal loop closes spontaneously. Intestinal peristaltic activity may advance the mop distally with obstruction occurring at various levels, most commonly the terminal ileum. Cases of transmural migration of surgical sponge several months to years after cholecystectomy have been reported.2Patil K.K. Patil S.K. Gorad K.P. et al.Intraluminal migration of surgical sponge: gossypiboma.Saudi J Gastroenterol. 2010; 16: 221-222Crossref PubMed Scopus (21) Google Scholar In a systematic review of transmural migration of gossypiboma, 64 cases were reported. Intestine was the most common site of impaction (75%) followed by bladder (n = 7) and stomach (n = 2). Spontaneous expulsion was reported in 4 cases only.3Zantvoord Y. Weiden R.M. van Hooff M.H. Transmural migration of retained surgical sponges: a systemic review.Obstet Gynecol Surv. 2008; 63: 465-471Crossref PubMed Scopus (47) Google Scholar Diagnosis of gossypiboma should always be considered in a patients presenting with vague abdominal complaints after surgery. Imaging, particularly computed tomography (CT), plays an important role in diagnosis. Besides confirming a diagnosis of intestinal obstruction, CT allows a rather confident diagnosis of intraluminal sponge. The CT findings of a sponge include a rounded mass with whorl-like appearance with trapped air bubbles.2Patil K.K. Patil S.K. Gorad K.P. et al.Intraluminal migration of surgical sponge: gossypiboma.Saudi J Gastroenterol. 2010; 16: 221-222Crossref PubMed Scopus (21) Google Scholar A hyperdense capsule and spotted calcification may also be seen. On ultrasonography, the sponge appears as an echogenic mass with dense shadowing. The patient underwent laparotomy and removal of surgical sponge (Figure D, arrow) from the ileum (Figure D, short arrow).