Case Presentation: A 69- year- old man with a past medical history of sigmoidectomy, colorectal anastomosis and loop ileostomy for a large bowel obstruction due to sigmoid stenosis one month prior presented with coffee ground emesis and abdominal pain. Physical exam was notable only for tachycardia. His labs were notable for a white blood cell count of 26,000 cells/µL and a platelet count of 821,000. CT scan of abdomen and pelvis revealed mural thickening of the esophagus with concern for esophagitis and loculated gas and fluid collection in the inferior aspect of the spleen concerning for an abscess. The splenic collection was drained percutaneously, but the specimen had no leukocytes in the fluid, had a negative gram stain, and did not grow any organisms on culture. The patient underwent EGD and was found to have a duodenal ulcer. He improved following endoscopic intervention and medical management. On chart review, it was found that large volumes of Fibrillar Surgicel had been used during the patient’s bowel resection.
Discussion: Fibrillar Surgicel mimicking an abscess is a rare, but important complication that can occur following a surgical procedure. Surgicel is used as a hemostatic agent and can lead to collections in tissues, such as the spleen. These collections can appear to be abscesses on CT scans, leading to unnecessary interventions, such as drainage and antibiotic usage. The uptake of Surgicel is dependent on several factors including the volume used and the amount saturated in the blood. Oxidized Regenerated Cellulose (ORC) seen in Surgicel can still be seen in the body up to 45 days after placement. While being broken down, ORC can trap air giving the appearance of an abscess. Magnetic resonance imaging (MRI) has been proposed as an alternative tool to distinguish an abscess from degenerating Surgicel.
Conclusions: In our case, the transient leukocytosis was explained by an upper GI bleed as opposed to an infectious process. It is vital that clinicians not anchor on imaging findings and consider alternative diagnoses in the context of each patient’s history.
