Radiological Diagnosis

WANDERING INFARCTED SPLEEN

Abdominal US shows a large well-capsulated, uniformly hypoechoic mass in the hypogastric region showing some hyperechoic areas.

CT of the abdomen shows a uniformly hypodense, well-capsulated mass in the pelvis without any significant enhancement. The normal spleen is not visualised in the left hypochondrium.

Duplex Doppler (not shown) revealed no vascularity in the mass with evidence of a thrombosed vessel running almost parallel to the aorta entering the hilum of the mass with no detectable flow.

Selective celiac, superior mesenteric and renal angiograms were performed. The celiac run showed a long narrow splenic artery running almost parallel to the aorta and showing gradual tapering with complete block at the lower end [Figure - 4]. The mass did not show any enhancement on the angiogram.

Structural variations of the spleen include absent and ectopic spleen and splenunculae. Any of these by themselves are rare. The spleen may be located in the left flank of the mid abdomen or the left lower quadrant or the pelvis. Such instances of wandering spleen are rare, and they constitute a diagnostic challenge since the findings are non-specific. [1] Wandering (ectopic) spleen poses a difficult diagnosis particularly in children. [2] Wandering (ectopic) spleen commonly presents with splenic infarction secondary to torsion. [3] It has been reported in 0 to 0.4 percent of splenectomies. [4] It usually occurs at 20 to 40 years of age, and mostly is seen in women. Diagnosis is difficult. The patient usually has an asymptomatic abdominal mass, or acute abdomen, or a mass associated with pain.

Laboratory data is non-specific and diagnosis can be confirmed by imaging studies. CT and duplex US are preferred modalities. [5] Diagnosis is important in symptomatic cases since symptoms derive from torsion, which carries possible complications of infarction, gangrene and abscess; the mortality is 50% in such patients. [6]

Earlier, splenectomy was the treatment of choice, but recent reports suggest that the organ may be detorsed and splenopexy performed. [3] Splenectomy should be done only after there is no evidence of splenic blood flow after detorsion of the spleen. Although rare, torsion of the wandering spleen is to be considered in the differential diagnosis of patients with acute abdominal pain [7].