Gossypiboma: An Unusual Cause of Gastric Outlet Obstruction Diagnosed by Endoscopy

Abstract

Purpose: A gossypiboma, or retained surgical sponge is an uncommon surgical complication. Imaging plays a vital role in identifying retained foreign objects. To the best of our knowledge, it has been been rarely reported for gossypiboma to cause gastric outlet obstruction. We are reporting a case of gastric outlet obstruction caused by gossypiboma and diagnosed primarily by upper GI endoscopy. Results: A 40-year-old man presented with upper abdominal pain and persistent vomiting for three days prior to admission. The pain was epigastric, non radiating and without any aggravating or relieving factors. He denied history of weight loss, melena or hemetemesis. He had a past history of cholecystectomy done abroad 3 years ago. His general physical examination was unremarkable. Abdominal examination revealed a healed right subcostal scar of open cholecystectomy. On palpation, there was an intra-abdominal firm mass in the right hypochondrium. His hemogram, biochemical parameters, chest x-ray films were normal. After informed consent and overnight fasting, an upper GI endoscopy revealed stomach partially filled with fluids and food particles. Examination was not completed because of fear of aspiration. On repeat endoscopy after a longer fasting period, a fixed foreign body in the antrum obstructing the pylorus was seen. The foreign body had an appearance of woven fiber; a few fibers were removed using biopsy forceps, which suggested a surgical sponge. A contrast-enhanced CT scan of the abdomen revealed a foreign body with radiopaque segment in the proximal duodenum and pylorus with local peritonitis causing gastric outlet obstruction and hyperdistension of the stomach with some free fluid in the pelvis. There was no free air seen. The patient underwent surgical exploration, which confirmed the diagnosis. The sponge was removed, and the fistulous communication was repaired. Conclusion: Although gossypiboma is rarely seen in routine clinical practice, it should be considered in the differential diagnosis of acute mechanical gastrointestinal obstruction in patients who underwent laparotomy in the past. Early recognition of this condition may prompt appropriate investigation and treatment which may reduce morbidity and mortality. The best known approach in the prevention of this condition is meticulous counting of radiopaque surgical material in addition to a thorough evaluation of surgical site at the end of operation.