Case 1
A 39-year-old female with the chief presenting complaint of on and off bleeding and serous discharge per vaginam for 1 year. The patient gave a history of total abdominal hysterectomy done for uterine fibroid at another medical facility 2 years back. USG examination revealed a complex heterogeneous mass in the pelvis. CECT abdomen revealed, a defined heterogeneous mass located posterior to the UB in the cul de sac. The lesion showed heterogeneous enhancement with multiple tiny non enhancing fluid density components. There was no mottled air within the lesion (Fig. 1a). The possibility of an inflammatory pseudo mass was suggested. Exploratory laparotomy done revealed a globular inflammatory mass bulging posterior to the bladder, 12x 12 cm in size filled with a surgical mop of approx 16 x17 cm and purulent material (Fig. 1b, c).
Case 2
A 72-year-old male who presented with heaviness and discomfort in the right upper abdomen for the last 4 years. The patient gave a history of open cholecystectomy done 10 years ago at another medical facility. Physical examination revealed a firm 6x6 cm non-tender lump in right hypochondrium per abdominal examination. USG examination suggested the possibility of intraperitoneal hydatid cyst in the right hypochondrium. CECT abdomen showed an intraperitoneal complex cystic lesion in the right hypochondrium with an internal lamellated membrane and a diagnosis of hydatid Cyst was suggested (Fig. 2a). However, IgG and IgM were negative for Echinococcus granulosus. Intraoperatively a capsulated gauze of 9 x 8 cm was present in the peritoneal cavity in right subhepatic region densely adherent to the inferior surface of the right lobe of the liver, omentum and adjacent bowel with purulent material inside the capsule (Fig. 2b,c).
Case 3
A 26-year-old female presented with pain and purulent discharge from the incision site for 3 months following total abdominal hysterectomy performed in another hospital 4 months back. Physical examination showed a sinus tract was noted in the lower part of the incision with an underlying, irreducible, mobile lump of 10x 8 cm. USG abdomen suggested a complex inflammatory mass in the supravesical region. CECT showed a well defined thick-walled
heterogenous intra-peritoneal collection measuring 6x9x 10 cm in supravesical region in midline suggestive of an abscess. The lesion showed mottled air loculi in the center indicating a possibility of retained sponge (Fig. 3a). Exploratory laparotomy revealed a 10x 8 cm surgical gauze present adherent to the posterior surface of the bladder and adjacent bowel with foul-smelling purulent material (Fig. 3b).
Case 4
A 35-year-old female presented with diffuse abdominal pain for 4 years. The patient had undergone open appendicectomy 10 years back and revealed no other history of other surgical intervention or abdominal trauma. On examination, the abdomen was distended with diffuse tenderness. tachycardia and blood pressure of 100/50 mm Hg. CECT revealed a large tubular structure of metallic attenuation extending from ileal loop to sigmoid colon lumen, with adjacent clumped and adhered small bowel loops (Fig. 4). A possibility of iatrogenic foreign body (likely broken surgical instrument) with suspicious fistulous communication between the sigmoid colon and small bowel (ileocolic fistula) was kept. The patient developed sepsis and was shifted to the ICU for hemodynamic and ventilator support. The patient expired before surgery could be performed. The family denied the autopsy.
Case 5
A 62-year-old man underwent laparoscopic cholecystectomy and 1 week after discharge developed intense pain in the right upper abdomen. Ultrasound showed moderate free fluid in GB fossa and perihepatic regions. The patient underwent ERCP which revealed biliary leak through the cystic duct. A double pigtail plastic stent was placed. The patient was lost to follow up for the next 2 months. Two and half months later the patient presented with colicky abdominal pain, vomiting, and distension of bowel. CECT of the abdomen was performed with oral and intravenous contrast administration. A few dilated ileal loops were seen in the umbilical region with abrupt narrowing of the lumen suggestive of intestinal obstruction (Fig. 5a). On adjusting window settings, a coiled tubular structure was observed at the site of abrupt narrowing (Fig. 5b). The plastic biliary stent was not seen in CBD. A diagnosis of the migrated biliary stent causing intestinal obstruction was made and the patient was taken up for laparotomy and surgical removal of the stent.
Case 6
A 30-year-old P2 L2 female presented with a history of lower abdominal pain for 1 week. She had undergone intracaesarean placement of intrauterine contraceptive device (Cu-T) that was placed 6 months ago. 3 months after the placement, she passed the IUD thread through the vagina. She presented to our hospital with cyclical pain abdomen and amenorrhea to our hospital for the last three months. Ultrasound and CECT abdomen revealed showed the presence of collection within the endometrial cavity suggestive of hematometra. Also, a hyperdense linear structure consistent with IUCD was seen in the right parametrium (Fig. 6). A diagnosis of post-surgical hematometra with misplaced IUCD was made and evacuation of hematometra and laparotomy was planned to remove the migrated IUCD. However, eventually, hysterectomy was performed with the retrieval of CU-T.
Case 7
A fifty-eight-year-old lady was referred for CECT abdomen for evaluation of postoperative sepsis. She underwent vaginal hysterectomy a day ago for uterine prolapse at an outside institute. Within hours after surgery, the patient became hypotensive and tachycardic.
Hemoglobin was 7 g/dl (from preoperative 11 g/dl)). Laparotomy was performed to arrest the bleeding. Subsequently, a day later, the patient was referred to our institute with sepsis. The patient was febrile and TLC was markedly raised (21000/ mm3). CT showed a large heterogeneous hematoma measuring approximately 14x 7x 4 cm in the pelvis and lower abdomen, posterior to the urinary bladder. A well hypodense structure was seen superior and anterior to the hematoma with multiple closely packed gas pockets within (Fig. 7a,b). A diagnostic suspicion of gossypiboma was made and the presumptive diagnosis was offered to the referring gynecology team.
However, after interacting with the operating surgeon, the re-evaluation of the scan was requested as the surgical sponge count was confirmed during and after surgery. The operating surgeon informed us that gelatine sponge (gel foam, Pharmacia) was used against the bleeding surface to produce hemostasis. To evaluate the imaging pattern of gelfoam, a scan of gelfoam soaked with blood, stuffed in surgical glove was obtained (Fig. 7c). Comparison with the scan and scrutiny of the pattern and morphology of the structure convinced us of the initial fallacy. The decision was made to conservatively manage the patient with i.v. antibiotic therapy. The patient gradually improved and was discharged after 7 days.