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A Patient With Abnormal Abdominal CT Scan Findings

Educational Objective
Based on this clinical scenario and the accompanying image, understand how to arrive at a correct diagnosis.
1 Credit CME

A 51-year-old man with a history of hypertension, hypercholesterolemia, and nephrolithiasis presented to the emergency department with left flank and left upper quadrant abdominal pain. He stated that “I think I have a kidney stone blocking my kidney” but denied nausea, vomiting, fever, dysuria, hematuria, or weight loss. He had no history of chronic abdominal pain. Past surgical history was noteworthy for emergency exploratory laparotomy and splenectomy for blunt trauma 14 years prior. Physical examination revealed a comfortable-appearing patient in no acute distress. His temperature was 36.8°C; pulse, 77/min; and blood pressure, 125/86 mm Hg. Abdominal palpation elicited only mild epigastric tenderness without masses or rebound. There was no costovertebral angle tenderness.

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Gossypiboma (retained surgical sponge)

C. Perform an exploratory laparotomy and excision of the mass

The key to the correct diagnosis is the remote history of a trauma laparotomy and the CT scan scout image that shows the characteristic finding of a radiopaque marker associated with a retained surgical sponge (Figure 2). All surgical sponges are equipped with such a marker, which manifests radiographically as a convoluted hyperdensity. These abdominal lesions may be confused with a gastrointestinal stromal tumor or other gastrointestinal malignancies. Since the lesion appears radiographically to be outside the lumen of the gastrointestinal tract, EGD has no role. Without a confirmed diagnosis of malignancy, laparoscopy with peritoneal washings to identify occult metastases would be premature. An interventional radiology–guided biopsy is unnecessary, given the early recognition of the radiopaque marker associated with gossypiboma.

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Article Information

Corresponding Author: Joseph M. Vitello, MD, Department of Surgery, Jesse Brown Veterans Administration and Medical Center, 820 S Damen Ave, Chicago, IL 60612 (jvituic@comcast.net).

Published Online: June 10, 2019. doi:10.1001/jama.2019.6849

Conflict of Interest Disclosures: None reported.

Additional Contributions: We thank the patient for providing permission to share his information.

References
1.
Gawande  AA, Studdert  DM, Orav  EJ, Brennan  TA, Zinner  MJ.  Risk factors for retained instruments and sponges after surgery.  N Engl J Med. 2003;348(3):229-235. doi:10.1056/NEJMsa021721PubMedGoogle ScholarCrossref
2.
Lincourt  AE, Harrell  A, Cristiano  J,  et al.  Retained foreign bodies after surgery.  J Surg Res. 2007;138(2):170-174. doi:10.1016/j.jss.2006.08.001PubMedGoogle ScholarCrossref
3.
McIntyre  LK, Jurkovich  GJ, Gunn  MLD, Maier  RV.  Gossypiboma: tales of lost sponges and lessons learned  [reprint].  Arch Surg. 2010;145(8):770-775. doi:10.1001/archsurg.2010.152PubMedGoogle ScholarCrossref
4.
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(2):481-489. doi:10.2214/ajr.180.2.1800481PubMedGoogle ScholarCrossref
5.
Stawicki  SPA, Moffatt-Bruce  SD, Ahmed  HM,  et al.  Retained surgical items: a problem yet to be solved.  J Am Coll Surg. 2013;216(1):15-22. doi:10.1016/j.jamcollsurg.2012.08.026PubMedGoogle ScholarCrossref
6.
Hempel  S, Maggard-Gibbons  M, Nguyen  DK,  et al.  Wrong-site surgery, retained surgical items, and surgical fires.  JAMA Surg. 2015;150(8):796-805. doi:10.1001/jamasurg.2015.0301PubMedGoogle ScholarCrossref
7.
Cima  RR, Kollengode  A, Garnatz  J,  et al.  Incidence and characteristics of potential and actual retained foreign object events in surgical patients.  J Am Coll Surg. 2008;207(1):80-87. doi:10.1016/j.jamcollsurg.2007.12.047PubMedGoogle ScholarCrossref
8.
The Joint Comission. Sentinel Event Alert: preventing unintended retained foreign objects. https://www.jointcommission.org/assets/1/6/SEA_51_URFOs_10_17_13_FINAL.pdf. October 17, 2013. Accessed April 12, 2019.
9.
Williams  TL, Tung  DK, Steelman  VM,  et al.  Retained surgical sponges: findings from incident reports and a cost-benefit analysis of radiofrequency technology.  J Am Coll Surg. 2014;219(3):354-364. doi:10.1016/j.jamcollsurg.2014.03.052PubMedGoogle ScholarCrossref
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