Emergency (****); * (*): *-* This open-access article distributed under the terms of the Creative Commons Attribution Non Commercial 3.0 License (CC BY-NC 3.0). Copyright © 2016 Shahid Beheshti University of Medical Sciences. All rights reserved. Downloaded from: www.jemerg.com 45 Emergency (2016); 4 (1): 45-46 PHOTO QUIZ A 52-Year-Old Woman with a Palpable Abdominal Mass Yuh-Jeng Yang1, Chin-Chu Wu2, Tzong-Luen Wang1,3, Aming Chor-Ming Lin1,3,4* 1. Emergency Department, Shin Kong Wu Ho-Su Memorial Hospital, Taipei, Taiwan. 2. Department of Diagnostic Radiology, Shin Kong Wu Ho-Su Memorial Hospital, Taipei, Taiwan. 3. School of Medicine, Fu-Jen Catholic University, New Taipei City, Taiwan. 4. Department of Intensive Care Unit, Shin Kong Wu Ho-Su Memorial Hospital, Taipei, Taiwan *Corresponding Author: Aming Chor-Ming Lin; Emergency Department, Shin Kong Wu Ho-Su Memorial Hospital, 95 Wen Chang Rd, Taipei, Taiwan. Tel: 886-02-28332211 Ext 2082; Fax: 886-02-28353547; E-mail: amingphd@yahoo.com.tw Received: Jun 2015; Accepted: August 2015 Case presentation: 52-year-old woman was presented to the emer- gency department with complaint of unspecific abdominal pain and a 2-week hypermenorrhea. The patient did not have nausea, vomiting, fever, or any other symptoms. She had a history of diabetes mellitus for which she was under medical treatment, and a surgi- cal history of a cesarean section 20 years ago. On arrival, she was vitally stable. Her blood pressure was 120/68 mmHg, with a heart rate of 82 beats/minute and a res- piratory rate of 20 breaths/minute. She was afebrile. Her abdominal examination revealed a lower segment cesar- ean section scar, lower abdominal fullness and a round mobile palpable mass in right lower quadrant. Bowel sounds were normal. Physical examination of all other parts did not show any positive findings. Complete blood cell count and biochemistry profiles were requested and all were reported in normal range. Carcinoembryonic antigen (CEA) as well as alpha-fetoprotein were also normal. The patient underwent abdominopelvic com- puted tomography (CT), the results of which are shown in Figure 1 and Figure 2. What is your diagnosis? A Figure 1: Axial view of patient’s abdominopelvic computed tomography. Figure 2: Coronal view of patient’s abdominopelvic com- puted tomography. This open-access article distributed under the terms of the Creative Commons Attribution Non Commercial 3.0 License (CC BY-NC 3.0). Copyright © 2016 Shahid Beheshti University of Medical Sciences. All rights reserved. Downloaded from: www.jemerg.com Yuh-Feng et al 46 Diagnosis: Abdominopelvic CT revealed an 8×7×6 cm round well- defined soft tissue mass containing cystic and solid com- ponents in the lower right abdominal area, suggesting a gynecologic tumor. A surgical resection of the tumor was performed, and the macroscopic pathological study re- vealed a gossypiboma inside the mass with a foreign body reaction. Case fate: With concern of right ovarian carcinoma, she underwent an exploratory laparotomy. An encapsulated sponge sur- rounded by omentum was removed. The patient had an uneventful postoperative recovery and was discharged two days later. Discussion: Retained surgical sponge or gossypiboma, is an infre- quent but serious surgical complication that may lead to significant medicolegal problems (1, 2). The incidence of retained foreign bodies following surgery has a reported rate of 0.06% to 0.1%. However, as gossypiboma is asymptomatic in many patients, its incidence is often un- derestimated (3). Gossypibomas are most frequently discovered in the abdomen but also reported in other parts of the body (4). It can be a challenging diagnosis due to the wide range of presentations. The clinical presentations vary and depend on location and size of the foreign body. Inflammatory body reaction, including exudative and aseptic fibrous, can also affect its manifes- tations (3, 5). In our case, the natural evolution of a re- tained sponge caused a foreign body reaction to form a foreign granuloma that mimicked a soft tissue neoplasm. Gossypiboma in the abdomen can be misdiagnosed as mass or cyst (5). The clinical presentation may present as acute or chronic abdominal pain, abscess formation, fistula formation, perforation, intestinal obstruction or bleeding (6). Diagnosis of the gossypiboma can be made by various imaging methods such as x-ray, ultrasonogra- phy (US), CT, magnetic resonance imaging (MRI) or fluorodeoxyglucose positron emission tomography (FDG-PET) (3, 7, 8). However, generally CT is recom- mended as the best option for this purpose in suspected cases. The CT radiographic features of abdominal gossy- pibomas include low-density mass with a thin enhancing capsule and spongiform appearance with gas bubbles (9, 10). Operative removal of the foreign body must almost always be performed along with treating its complica- tions. There are some case reports for other options such as colonoscopy (11-13). Conclusion: A high index of suspicion is needed to diagnose gossypi- boma. Retained foreign body should be in the differential diagnosis of patients with a history of previous opera- tion. Acknowledgments: We acknowledge all staff of emergency department of Shin Kong Wu Ho-Su Memorial Hospital, Taipei, Taiwan. Conflict of interest: None Funding support: None Authors’ contributions: All authors passed four criteria for authorship contribu- tion based on recommendations of the International Committee of Medical Journal Editors. References: 1. Silva SM, Sousa JBd. Gossypiboma after abdominal surgery is a challenging clinical problem and a serious medicolegal issue. ABCD Arquivos Brasileiros de Cirurgia Digestiva (São Paulo). 2013;26(2):140-3. 2. Rajagopal A, Martin J. Gossypiboma—“A Surgeon’s Legacy”. Diseases of the colon & rectum. 2002;45(1):119-20. 3. Rappaport W, Haynes K. The retained surgical sponge following intra-abdominal surgery: a continuing problem. Archives of Surgery. 1990;125(3):405-7. 4. Mavioglu L, Ertan C, Mungan U, Ozatik MA. Paracardiac Gossypiboma (Textiloma) in 2 Patients. Texas Heart Institute Journal. 2015;42(3):259-61. 5. Rajput A, Loud PA, Gibbs JF, Kraybill WG. Diagnostic challenges in patients with tumors Case 1. Gossypiboma (foreign body) manifesting 30 years after laparotomy. Journal of clinical oncology. 2003;21(19):3700-1. 6. Karaoglan M, Ipekci F, Sert I, Ozturk S, Sahin AG. Massive upper and lower gastrointestinal bleeding due to intra- abdominal gossypiboma. Elective Medicine Journal. 2015;2(4):426-7. 7. Gümüs M, Gümüs H, Kapan M, Önder A, Tekbas G, Baç B. A serious medicolegal problem after surgery: gossypiboma. The American journal of forensic medicine and pathology. 2012;33(1):54-7. 8. Yuh-Feng T, Chin-Chu W, Cheng-Tau S, Min-Tsung T. FDG PET CT features of an intraabdominal gossypiboma. Clinical nuclear medicine. 2005;30(8):561-3. 9. O'Connor AR, Coakley FV, Meng MV, Eberhardt S. Imaging of retained surgical sponges in the abdomen and pelvis. American journal of roentgenology. 2003;180(2):481-9. 10. Manzella A, Filho PB, Albuquerque E, Farias F, Kaercher J. Imaging of gossypibomas: pictorial review. American Journal of Roentgenology. 2009;193(6_supplement):S94-S101. 11. Lauwers PR, Van Hee RH. Intraperitoneal gossypibomas: the need to count sponges. World journal of surgery. 2000;24(5):521-7. 12. Hinrichs C, Methratta S, Ybasco AC. Gossypiboma treated by colonoscopy. Pediatric radiology. 2003;33(4):261-2. 13. Yildirim S, Tarim A, Nursal TZ, et al. Retained surgical sponge (gossypiboma) after intraabdominal or retroperitoneal surgery: 14 cases treated at a single center. Langenbeck's Archives of Surgery. 2006;391(4):390-5.