Beyond the Spongiform Pattern of Gossypiboma: How a Radiopaque Marker Solved the Mystery of a Retained Sponge

Abstract

Gossypiboma, a retained surgical foreign body, is a rare but serious complication with variable clinical and radiological features, posing diagnostic challenges. This case report describes a 55-year-old female with a history of total abdominal hysterectomy and incisional hernioplasty, presenting with a 6-month history of insidious abdominal pain and a palpable right iliac fossa mass. Initial ultrasound suggested a mesenteric dermoid, but her surgical history raised suspicion of gossypiboma. Computed tomography revealed a nonenhancing hypodense lesion with a curvilinear high-density structure (average attenuation of 1200 HU) within causing streak artifacts, characteristic of a radiopaque surgical sponge marker, confirming the diagnosis. Exploratory laparotomy identified an encapsulated surgical mop with dense adhesions, necessitating adhesiolysis, appendectomy, and ileal resection. The postoperative course was uneventful. This case highlights the importance of considering gossypiboma in patients with prior surgery, even without classic imaging features, and underscores the critical role of radiopaque markers in diagnosis.

 

MissingLinkText

Keywords

gossypiboma - retained sponge - radiopaque marker

Introduction

Gossypiboma refers to a mass formed by cotton woven gauze sponge surrounded by a granulomatous inflammatory reaction.[1] Retained foreign body (RFB), frequently consists of soft foreign bodies—such as surgical sponges or gauze—which account for approximately 90% of reported cases. In contrast, hard foreign bodies, including surgical instruments or needles, are retained with markedly lower incidence.[2]

On computed tomography (CT), they typically exhibit a spongiform pattern with a whorled texture or mottled gas-like appearance.[3] Other less common presentations include calcified reticulate rind sign[4] (due to gradual calcification of the filaments of the sponge), low-density mass with thin enhancing capsule, and internal high-density metallic content. Ultrasound findings reveal hyperechoic lesion encircled by a hypoechoic border with strong posterior acoustic shadowing.[5] A retained surgical sponge typically appears as a well-encapsulated soft tissue mass with a whorled pattern on T2-weighted magnetic resonance imaging (MRI), often hypointense on T1 and hyperintense on T2.[6] However, MRI is less reliable compared with CT as radiopaque markers in sponges are neither magnetic nor paramagnetic, making them invisible on MRI.[7]

Here, we present a unique case of gossypiboma with an atypical radiological presentation, where the absence of classic spongiform patterns posed diagnostic challenges, but the presence of radiopaque marker on the retained sponge was pivotal in achieving an accurate diagnosis.

 

MissingLinkText

Case Presentation

A 55-year-old female patient was referred to our hospital with complaints of pain abdomen for 6 months, which was insidious in onset and gradually progressive. She gave history of total abdominal hysterectomy with bilateral salpingo-oophorectomy for abnormal uterine bleeding-fibroid 4 years ago and incisional hernioplasty 8 months ago. On clinical examination, an approximately 10 × 10 cm sized fixed hard mass was palpable in the right iliac fossa extending into the lumbar region. All the routine laboratory investigations were normal.

Initial radiological investigation performed was ultrasound, which revealed a well-defined hypoechoic mass in the right iliac fossa with internal hyperechoic content casting significant post-acoustic shadow. With these ultrasound findings, the initial differential diagnosis was mesenteric dermoid with “tip of iceberg” sign. However, in view of history of recent surgery, the possibility of a RFB was suspected ([Fig. 1]).

Fig. 1 Ultrasound. (A) Well-defined hypoechoic mass with internal hyperechoic content (yellow arrow) casting significant post-acoustic shadowing (orange arrow) in the right iliac fossa. (B) On color Doppler, no color uptake was seen within the lesion.

With this suspicion, triphasic abdomino-pelvic contrast-enhanced CT with delayed phase was performed. Positive oral contrast was also administered. It revealed a large, well-defined, round, hypodense lesion (an average attenuation of 28 HU) in the right iliac fossa with internal heterogeneously hyperdense content and very high-density (with an average attenuation of 1200 HU) curvilinear structure, producing thin alternating streak artifacts. The presence of this curvilinear high-density structure with streak artifacts on CT emphasizes its metallic nature, which is commonly seen in the surgical mops and this aligns closely with the clinical context of our case. Reconciliation of the clinical and imaging findings confirmed the diagnosis of a gossypiboma ([Fig. 2]).

Fig. 2 (A) Computed tomography (CT) plain study showing well-defined hypodense mass (yellow arrow) with internal hyperdense content and curvilinear metallic density structure (orange arrow). (B and C) Arterial and venous phase images, respectively, showing no enhancement.

This foreign body mass was seen eroding into the ileocecal junction, cecum, terminal ileal loops, and base of the appendix; however, there was no extravasation of the oral contrast into the mass. It was in close contact with the anterior abdominal wall ([Fig. 3]).

Fig. 3 (A) Oblique reformatted image showing adherence of the mass to the base of the appendix (green arrow). (B) Coronal reformatted image showing adherence of the mass to the cecum (orange arrow) and terminal ileal loop (yellow arrow).

She underwent exploratory laparotomy, revealing an encapsulated surgical mop in a contained collection from which approximately 500 mL pus was drained. It showed dense adhesions with the adjacent terminal ileal loops, ileocecal junction, base of the appendix, and anterior abdominal wall for which adhesiolysis was performed. However, adhesions with appendix and terminal ileal loops could not be released; hence, appendectomy with terminal ileal resection and side-to-side anastomosis was performed. Finally, milking of the intestinal loops was performed to rule out bowel perforation. Postoperative course was uneventful ([Fig. 4]).

Fig. 4 (A) Intraoperative image showing the lesion (black arrow). (B) Intraoperative image showing greenish pus collection (black arrow).

 

MissingLinkText

Discussion

Gossypiboma is a rare but serious complication of surgical procedures. Despite advancements in surgical protocols and counting techniques, cases of RFBs continue to occur due to various factors like emergency surgeries, lengthy procedures, obese patients, etc.[8] This case highlights the diagnostic challenges posed by gossypiboma, due to its atypical radiological features, and emphasizes the importance of high suspicion in patients with history of prior surgery.

Clinicians often assume that diagnosing an RFB on a pre- or an intraoperative radiograph is straightforward, but this is frequently not the case. Intraoperative radiographs can pose difficulty in image acquisition resulting in poor image quality, particularly in obese patients, and identifying a sponge correctly can be challenging. Surgical markers may become twisted or folded, creating unusual and misleading images and these markers can be misinterpreted as calcifications, wires, or surgical clips.[9]

Typically, a retained sponge may present with spongiform pattern on CT, characterized by a whorled texture or gas bubbles within the mass.[8] However, in this case, the presence of a curvilinear high-density structure with streak artifacts on CT scan was pivotal in confirming the diagnosis. This finding is characteristic of the radiopaque marker found in surgical mops, which is often the key to identifying gossypiboma on imaging.[9] Aminian showed similar presentation of gossypiboma in the form of soft tissue mass with internal curvilinear high-density structure.[9]

The standard treatment for an RFB is surgical removal. In our case, the gossypiboma had developed into a walled-off collection with dense adhesions to the appendix and terminal ileum, necessitating resection to ensure complete removal of the retained mop.

 

MissingLinkText

Conclusion

The present case serves as an important reminder to be aware of various presentations of gossypiboma, its risk factors, and proactive measures to prevent it. Although gossypibomas are rare and often asymptomatic, they can be challenging to diagnose. Chronic cases may lack specific clinical or radiological signs like the spongiform appearance, making differential diagnosis difficult. Therefore, gossypiboma should always be considered in the differential diagnosis of soft tissue masses, especially in patients with a history of prior surgery. Awareness and preventive strategies are crucial to avoid this preventable complication.

 

MissingLinkText

 

MissingLinkText

Conflict of Interest

None declared.

• References

• 1 Van der Weiden RM. A foreign body (gossypiboma) in pregnancy: first report of a case. Gynecol Surg 2007; 4 (01) 61
• 2 Modrzejewski A, Kaźmierczak KM, Kowalik K, Grochal I. Surgical items retained in the abdominal cavity in diagnostic imaging tests: a series of 10 cases and literature review. Pol J Radiol 2023; 88: e264-e269
• 3 Pole G, Thomas B. A pictorial review of the many faces of gossypiboma–observations in 6 cases. Pol J Radiol 2017; 82: 418-421
• 4 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 (31) 4927-4929
• 5 Shyung LR, Chang WH, Lin SC, Shih SC, Kao CR, Chou SY. Report of gossypiboma from the standpoint in medicine and law. World J Gastroenterol 2005; 11 (08) 1248-1249
• 6 O'Connor AR, Coakley FV, Meng MV, Eberhardt SC. Imaging of retained surgical sponges in the abdomen and pelvis. AJR Am J Roentgenol 2003; 180 (02) 481-489
• 7 Puri A, Anchan C, Jambhekar NA, Agarwal MG, Badwe RA. Recurrent gossypiboma in the thigh. Skeletal Radiol 2007; 36 (Suppl. 01) S95-S100
• 8 Lauwers PR, Van Hee RH. Intraperitoneal gossypibomas: the need to count sponges. World J Surg 2000; 24 (05) 521-527
• 9 Aminian A. Gossypiboma: a case report. Cases J 2008; 1 (01) 220

Publication History

Article published online:
30 July 2025