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ABDOMINAL IMAGING Table of Contents   
Year : 2002  |  Volume : 12  |  Issue : 3  |  Page : 359-362
Wandering spleen : Unusual presentation and course of events


Dept of Radiodiagnosis, K.G. Hospital and Post graduate Medical Institute Arts College Road , Coimbatore-641018, Tamilnadu, India

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Keywords: Wandering Spleen, Splenic torsion, Splenic infarct, Splenopexy

How to cite this article:
Dahiya N, Karthikeyan D, Vijay S, Kumar T, Vaid M. Wandering spleen : Unusual presentation and course of events. Indian J Radiol Imaging 2002;12:359-62

How to cite this URL:
Dahiya N, Karthikeyan D, Vijay S, Kumar T, Vaid M. Wandering spleen : Unusual presentation and course of events. Indian J Radiol Imaging [serial online] 2002 [cited 2019 Nov 18];12:359-62. Available from: http://www.ijri.org/text.asp?2002/12/3/359/28483

   Introduction Top


Wandering spleen is a rare entity in which the spleen is attached by a long, vascular pedicle and is without its usual peritoneal attachments. The spleen can be found in any part of the abdomen or pelvis because of the length of its pedicle. The abnormally fixed spleen can twist on its vascular pedicle, creating ischemia that may progress to infarction if not promptly treated. Clinical presentation of wandering spleen is varied and the diagnosis is often elusive. The clinical appearance can be acute or chronic; it can be seen as an asymptomatic mass, a mass with pain or an acute abdomen. Patients usually become symptomatic when torsion of the splenic pedicle occurs. Acute torsion may precipitate fever, vomiting and acute abdominal pain, while recurrent, chronic torsion and detorsion may present as intermittent colicky pain or vague abdominal discomfort. Early preoperative diagnosis is difficult without radiological aids. The usual treatment is fixation of the spleen (splenopexy), except in cases of infarction where splenectomy is preferred.

We present a case in which radiological diagnosis of wandering spleen was made in a patient referred for investigation of a pelvic mass. The same patient subsequently presented with acute abdomen and torsion of the wandering spleen was diagnosed preoperatively. A review of the history, diagnosis and treatment of wandering spleen is presented.


   Material and Methods Top


A 23-year-old married woman with a 15-month-old child presented to the Gynaecology out patient clinic in our hospital with complaints of recurrent dull-aching lower abdominal pain and irregular menstrual periods. She gave a history of IUCD (Copper-T) insertion after delivery. Physical examination by the gynecologist revealed a firm smooth mass in the left lower abdomen with mild tenderness on palpation. Vaginal examination revealed a normal uterus and fullness in the left fornix

Transabdominal sonography (Logiq 500 PRO, 4 MHz curvilinear transducer, GE, Milwaukee, USA) showed absence of the spleen in its normal location in the left upper quadrant. An enlarged spleen (measuring about 15 cm in length) was seen in the left iliac fossa superolateral to the uterus [Figure - 1]. Colour Doppler showed normal vascularity at the splenic hilum [Figure - 2] and in all parts of the spleen. The splenic artery had its normal origin from the coeliac trunk (not shown). Transvaginal sonography (not shown) confirmed the findings. Axial NECT section (CT e, GE, Milwaukee, USA. [Figure - 3] showed pelvic spleen with posterolateral hilum. The patient was treated conservatively and was advised to report immediately if the pain recurred.

Two weeks later the patient presented to the Emergency room with acute severe abdominal pain associated with nausea. Abdominal examination showed a firm tender mass in the left lumbar area with some localized guarding. Laboratory investigations showed leucocytosis (Total count 14.7 x 103/L) and mild anaemia (Haemoglobin 10.6 g/dL, Haematocrit 34.7%, Peripheral smear - Normocytic, mildly hypochromic anaemia with lymphocytosis). All the other investigations were within normal limits.

CT scan of the abdomen was done. The spleen was now seen at a higher level (anterior to the left psoas and lower pole of left kidney, [Figure - 4] than the previous scan with the hilum facing anterolateral. NECT sections showed focal low attenuation areas within the spleen [Figure - 4] CECT sections showed well-defined non-enhancing low-attenuation areas in the spleen consistent with splenic infarcts predominantly in the medial aspect. The splenic hilum (now seen facing anterolateral) and pedicle showed a whorled appearance with alternating high and low attenuation areas corresponding to enhancing vessels and fat respectively [Figure - 5],[Figure - 6],[Figure - 7],[Figure - 8]. CT section at the level of stomach confirms absence of spleen in the normal location [Figure - 9].

Radiological diagnosis of splenic infarct secondary to torsion of wandering spleen was made. Emergency laparotomy and splenectomy was done. The patient was discharged after an uneventful postoperative period.


   Discussion Top


Synonyms - Displaced Spleen, Drifting Spleen, Floating Spleen, Splenic Ptosis. Splenoptosis. Systopic Spleen.


   History and incidence Top


Van Horne, a Dutch physician, is credited with describing this condition in 1667 after performing an autopsy. In 1875, Martin, a German obstetrician, performed the first splenectomy for a wandering spleen. Ten years later, splenopexy was described and considered superior to splenectomy, a differential preference that has changed several times over the years. Since Van Horne's discovery, approximately 400 cases of wandering spleen have been reported worldwide.

The incidence of wandering spleen is unknown and is difficult to determine. It usually occurs between the ages of 20 and 40 years and 70% to 80% of cases are seen in women; most are of reproductive age at the time. Children make up one third of all cases and 30% of them are younger than 10 years of age. Under the age of 10 years, the male-female ratio is 1:1, but for those older than 10 years, the ratio is 1:7.

This variable incidence of wandering spleen according to age and sex can be explained by the two possible etiologies of this condition, which are acquired and congenital. The acquired from occurs in multiparous women as a result of hormonal changes during pregnancy. This causes a slackening of the abdominal wall and laxity of the ligaments normally attached to the spleen. In the congenital form, there is failure of normal development of the dorsal mesogastrium when the lesser sac is formed. The attachments of the dorsal mesentery to the posterior peritoneum and diaphragm are faulty. Suspensory ligaments of the spleen are not formed or are only partially formed. These include the phrenicosplenic, splenorenal, phrenicocolic, pancreaticosplenic, gastrosplenic, splenocolic and pancreatic colic ligaments. The length of its vascular pedicle determines mobility of the spleen in the absence of some or all of these ligaments. Some case reports have suggested that wandering spleen is a result of progressive splenomegaly due to diseases such as typhoid fever, lymphoma and especially malaria. This is unlikely because some wandering spleens are found to be of normal size or only moderately enlarged. A more likely explanation is that splenomegaly is secondary to chronic or recurrent torsion and subsequent venous congestion, not the primary disease process.


   Clinical presentation Top


Clinical presentation of wandering spleen is varied and the diagnosis is often elusive. Wandering spleen usually presents as asymptomatic abdominal mass, intermittent abdominal pain or acute abdomen. Sixty percent have a mass and pain. The nature of the pain reflects the degree of vascular occlusion and ischemia to the splenic pedicle. Acute torsion may precipitate fever, vomiting and acute abdominal pain, while recurrent, chronic torsion and detorsion may present as intermittent colicky pain or vague abdominal discomfort. Torsion can be precipitated by any movements of the body, changes in intra-abdominal pressure during respiration or peristalsis or distention of adjacent organs. Acute pancreatitis may be associated due to incorporation of the tail of the pancreas in the spleen's vascular pedicle. Gastric compression or distention may also occur.

On physical examination, patients with wandering spleen may present with a pelvic or abdominal mass that may or may not be associated with pain or tenderness. Physical findings vary with the pathophysiologic state of the spleen. The triad of a firm ovoid mass with a notched edge, painful movement of the mass except when the mass is moved toward the left upper quadrant and resonance to percussion in the left upper quadrant has been described to suggest the diagnosis of a wandering spleen. Wandering spleen can mimic several entities: tubo-ovarian abscess, ovarian cyst with torsion, uterine fibroid, urinary tract infection, acute appendicitis, intestinal obstruction, diverticulitis, colon cancer, cholecystitis, posttraumatic acute abdomen, extrauterine pregnancy and gastric haemorrhage. Laboratory values are often non-specific, however leucocytosis is generally present. Diagnosis of wandering spleen is very difficult with physical exam alone and often requires radiologic confirmation.


   Radiological findings Top


Conventional radiographs of the abdomen may demonstrate distended bowel loops and suggest a soft-tissue mass. Small-bowel loops in the left upper quadrant can be suggestive of a wandering spleen (as demonstrated in the CT scanogram of this case - [Figure - 10]. The most reliable and least invasive method of making the diagnosis is with ultrasonography. Sonography can demonstrate the morphology and homogeneous echotexture of the spleen and its absence from its normal position in the left upper abdomen (as in this case). Excessive gas within the bowel may obscure this finding. If the spleen's absence from the left upper quadrant has been confirmed, then evaluation of the vascular pedicle with Doppler studies may confirm decreased or absent blood flow to the ectopically located spleen that has undergone torsion

Radionuclide imaging complements ultrasonography. Liver-spleen scans utilizing technetium 99Tcm- sulphur colloid may demonstrate splenic displacement as well as the functional state of the spleen.51 Cr-tagged red cells are more specific and can prevent confusion with the left lobe of the liver. In cases with torsion and ischemia, the spleen may appear to be absent and only the liver may be imaged. Isotopic scanning, however, is nonspecific and there are other causes of acquired asplenia, such as sickle cell disease, thorotrast deposition, reticular cell sarcoma and situs inversus

CT shows wandering spleen and delineates other anatomic relationships. CT has the advantage of evaluating the tail of the pancreas as well as other normal or abnormal intra-abdominal structures. CT findings of wandering spleen include absence of spleen in the left upper quadrant and a soft-tissue mass resembling spleen elsewhere in the abdomen. If significant torsion of the splenic pedicle occurs, the torsed pedicle may mimic a bowel intussusception in appearance. The most specific sign of splenic torsion is a "whirl-like" (or 'whorled') appearance of splenic vessels and surrounding fat usually noted at the splenic hilum (as shown in this case). Occasionally, ascites or necrosis of the pancreatic tail can be seen. If torsion is chronic, a thick pseudocapsule is evident. The spleen is not enhanced by intravenous contrast medium if torsion has occurred and blood supply is lost.

Arteriography allows definitive evaluation of the splenic vasculature and signs of left-sided portal hypertension, if present. Several different radiologic modalities exist to diagnose a wandering spleen. Computed tomography and ultrasound are the most reliable imaging studies.


   Treatment Top


Definitive treatment for wandering spleen is operative, since nonoperative treatment is associated with a complication rate as high as 65%. Complications of wandering spleen include infarction, gangrene, splenic abscess, variceal haemorrhage and pancreatic necrosis. Historically, splenectomy has been used for wandering spleen, but with increased understanding of the spleen's function, splenopexy with splenic salvage is now the procedure of choice in children. However, the decision to perform splenopexy versus splenectomy depends on both the timing of clinical presentation and the appearance and viability of the spleen intraoperatively. In the emergent setting, the diagnosis of wandering spleen is usually made at laparotomy because patients present with an acute abdomen. The decision to perform splenopexy or splenectomy depends on the viability of the spleen after detorsion. If the spleen appears infarcted, a splenectomy should be performed. Splenopexy is a reasonable option when the spleen appears viable after detorsion and the splenic vein is not thrombosed. Results of splenopexy are considered good.[7]

 
   References Top

1.Duperier T, Schmidt H, Davies R. Wandering Spleen: An unusual presentation of Abdominal Pain. Contemporary Surgery, 2001; 57: 520-524.  Back to cited text no. 1    
2.Desai D C, Hebra A, Davidoff A M, Schnaufer L. Wandering spleen A challenging diagnosis. South Med J. 1997; 90: 439 - 443.  Back to cited text no. 2    
3.Allen KB, Gay BB Jr, Skandalakis JE. Wandering spleen: anatomic and radiologic considerations. South Med J. 1992; 85: 976-984.  Back to cited text no. 3    
4.Gayer G, Zissin R, Apter S, Atar E, Portnoy O, Itzchak Y. CT findings in congenital anomalies of the spleen. BJR. 2001; 74: 767-772.  Back to cited text no. 4    
5.Raissaki M, Prassopoulos P, Daskalogiannaki M, Magkanas E, Gourtsoyiannis N. Acute abdomen due to torsion of wandering spleen: CT diagnosis. Eur Radiol. 1998; 8: 1409-1412.  Back to cited text no. 5    
6.Swischuk LE, Williams JB. John SD. Torsion of wandering spleen: the whorled appearance of the splenic pedicle on CT. Pediatr Radiol. 1993; 23: 476-477  Back to cited text no. 6    
7.Nemcek AA Jr, Miller FH, Fitzgerald SW: Acute torsion of a wandering spleen diagnosis by CT and duplex Doppler and color flow sonography. Am J Radiol. 1991;157: 307-309.  Back to cited text no. 7    

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Correspondence Address:
N Dahiya
Dept of Radiodiagnosis, K.G. Hospital and Post graduate Medical Institute Arts College Road , Coimbatore-641018, Tamilnadu
India
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Source of Support: None, Conflict of Interest: None


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    Figures

[Figure - 1], [Figure - 2], [Figure - 3], [Figure - 4], [Figure - 5], [Figure - 6], [Figure - 7], [Figure - 8], [Figure - 9], [Figure - 10]

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