wandering spleen with torsion radiology

• Wandering spleen

Citation, DOI, disclosures and case data

At the time the case was submitted for publication Oscar Gutierrez had no financial relationships to ineligible companies to disclose.

Presentation

Severe abdominal pain in the left hypochondriac region after physical assault.

Patient Data

The spleen is not seen in the anatomical location.

In the left iliac fossa, there is a well-defined homogeneously enhancing oval-shaped soft tissue density mass of about 9 cm in its craniocaudal axis, which is vascularized by an elongated splenic artery that originated from the celiac trunk and venous drainage is mainly within the left renal vein.

Dorsolumbar scoliosis.

Bone remodeling in both hips probably related to bilateral congenital dysplasia.

Case Discussion

This case demonstrates a wandering spleen , a rare finding that is usually asymptomatic. It may be congenital (as in this case) or acquired and can often be an incidental finding when performing abdominal imaging tests for other reasons.

Patients with this condition are at increased risk of developing splenic torsion and splenic infarction, so in some cases, splenopexy may be considered as a treatment.

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A “wandering spleen”

• Classics in Abdominal Radiology
• Published: 15 February 2018
• Volume 43 , pages 2525–2526, ( 2018 )

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• Pengcheng Zhang   ORCID: orcid.org/0000-0001-5836-2838 1 ,
• Raymond B. Dyer 1 &
• Brenda L. Holbert 1  

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Gordon DH, Burrell MI, Levin DC, Mueller CF, Becker JA (1977) Wandering spleen—the radiological and clinical spectrum. Radiology 125:39–46

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Priyadarshi RN, Anand U, Kumar B, Prakash V (2013) Torsion in wandering spleen: CT demonstration of whirl sign. Abdom Imaging 38(4):835–838

Lebron R, Self M, Mangram A, Dunn E (2008) Wandering spleen presenting as recurrent pancreatitis. JSLS 12(3):310–313

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Department of Radiology, Wake Forest Baptist Medical Center, Wake Forest University School of Medicine, 1 Medical Center Blvd, Winston-Salem, 27157, NC, USA

Pengcheng Zhang, Raymond B. Dyer & Brenda L. Holbert

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Zhang, P., Dyer, R.B. & Holbert, B.L. A “wandering spleen”. Abdom Radiol 43 , 2525–2526 (2018). https://doi.org/10.1007/s00261-018-1488-1

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Published : 15 February 2018

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DOI : https://doi.org/10.1007/s00261-018-1488-1

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• Wandering Spleen
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Wandering Spleen

Wandering spleen can be found on imaging studies as a spleen that is located somewhere other than it’s usual position in the left upper abdomen.  This article will discuss diagnosis, complications and treatment of wandering spleen.

What is Wandering Spleen?

A wandering spleen, also known as a floating spleen or splenoptosis, is a condition where the spleen migrates from its usual position in the upper left abdomen. The spleen is a crucial organ involved in filtering blood and fighting infections.

In individuals with a wandering spleen, the ligaments that hold the spleen in place are either elongated or weakened, allowing it to move freely within the abdomen. This mobility can lead to various health issues, including abdominal pain, bloating, and in severe cases, spleen torsion or infarction, where the blood supply to the spleen is cut off, leading to tissue death.

Symptoms of Wandering Spleen

The symptoms of a wandering spleen can vary widely from person to person. Some individuals may not experience any symptoms at all, while others may have noticeable signs. Common symptoms include:

– **Abdominal pain or discomfort:** Often reported in the lower abdomen and may vary in intensity. – **A palpable mass:** Some patients may feel a movable lump in their abdomen. – **Gastrointestinal symptoms:** Such as bloating, constipation, or indigestion.

In cases where the spleen becomes twisted (torsion), symptoms can quickly escalate to sharp abdominal pain, vomiting, and fever, necessitating immediate medical attention.

Causes and Risk Factors

The exact cause of a wandering spleen is not always clear, but it is often related to the weakening or malformation of the ligaments that secure the spleen. This condition can be congenital (present at birth) or acquired due to injury, pregnancy, or previous abdominal surgeries. Factors that may increase the risk of developing a wandering spleen include:

– **Ligamentous laxity:** Natural or acquired looseness of the ligaments. – **Trauma:** Abdominal injuries that may damage spleen ligaments. – **Pregnancy and childbirth:** Hormonal changes and physical strain can weaken abdominal structures.

Diagnosis of Wandering Spleen

Diagnosing a wandering spleen involves a combination of physical examinations, medical history, and imaging tests. Physicians may initially suspect the condition based on symptoms and a physical exam. Diagnostic imaging, such as ultrasound, CT scans, or MRI, plays a crucial role in confirming the diagnosis by visually locating the spleen’s position and assessing its condition.

Treatment Options

The treatment for a wandering spleen depends on the severity of the symptoms and the overall health of the patient. Options include:

– **Observation:** In asymptomatic cases, regular monitoring may be recommended. – **Surgical intervention:** For symptomatic patients, surgery is often necessary. The two main surgical options are: – **Splenopexy:** Reattaching the spleen to its correct position using synthetic materials or tissue. – **Splenectomy:** Removal of the spleen, typically reserved for cases where the spleen is damaged or has become necrotic.

Post-Treatment Care and Considerations

After treatment for a wandering spleen, patients will need to follow up with their healthcare provider for regular check-ups. If the spleen was removed, vaccinations against certain bacteria may be recommended since the spleen plays a critical role in fighting infections. Patients who undergo splenopexy should avoid activities that may risk abdominal trauma to prevent recurrence.

A wandering spleen is a rare condition that can lead to significant health issues if not properly addressed. Understanding the symptoms, causes, and available treatment options is important for anyone diagnosed with this condition. With timely and appropriate medical care, individuals with a wandering spleen can lead healthy and active lives. Always consult with a healthcare provider for an accurate diagnosis and personalized treatment plan tailored to your specific needs.

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Affiliations.

• 1 Medical College, Aga Khan University, Stadium Road, Karachi, 74800, Pakistan. [email protected].
• 2 Medical College, Aga Khan University, Stadium Road, Karachi, 74800, Pakistan.
• 3 Department of Surgery, Aga Khan University, Karachi, Pakistan.
• PMID: 38615066
• PMCID: PMC11016203
• DOI: 10.1186/s13256-024-04502-6

Background: Wandering spleen (or ectopic spleen) refers to a hyper-mobile spleen resulting in its displacement from the normal anatomical position to usually in the lower abdominal or pelvic cavity. While ultrasound is often the first radiological modality used, Computed Tomography (CT) shows a clear picture and aides to reach a diagnosis. In circumstances where appropriate imaging modalities are not available, or the operator is inexperienced, diagnosis of wandering spleen can be missed.

Case presentation: A 22-nulligravida unmarried Sindhi female had presented to the Emergency Room (ER) with a 5-day history of intermittent severe lower abdominal pain. An ultrasound at a local practitioner had suggested an ovarian cyst. Ultrasound-pelvis and later CT scan at our facility reported an enlarged wandering spleen with torsion of its pedicle and infarction. Exploratory laparotomy with splenectomy was done. An enlarged wandering spleen was found with torsion of the splenic vein and thrombosed arterial supply from omentum wrapped over the mass. The patient developed thrombocytosis post-surgery but otherwise did well and was discharged after 2 days.

Conclusion: Splenic torsion secondary to a wandering spleen can be challenging to diagnose, especially in resource limited settings where ultrasound might be the only modality available. Timely diagnosis and proper intervention are key to saving the life and the spleen.

Keywords: Ovarian cyst; Splenectomy; Splenic torsion; Wandering spleen.

© 2024. The Author(s).

Publication types

• Case Reports
• Ovarian Cysts* / diagnostic imaging
• Ovarian Cysts* / surgery
• Splenic Diseases* / diagnostic imaging
• Splenic Diseases* / surgery
• Splenomegaly
• Wandering Spleen* / diagnosis
• Wandering Spleen* / diagnostic imaging

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Torsion of a Wandering Spleen

Hicham el bouhaddouti.

Department of Digestive Surgery, University Hospital Hassan II Fes, Morocco

Jihane Lamrani

Abdellatif louchi, mounia el yousfi.

1 Department of Gastroenterology, University Hospital Hassan II Fes, Morocco

Noureddine Aqodad

Adil ibrahimi, meriem boubou.

2 Department of Medical Imaging, University Hospital Hassan II Fes, Morocco

Imane Kamaoui

Siham tizniti.

Wandering spleen is a rare condition defined as a mobile spleen only attached with its pedicle. It can be complicated by a volvulus, which is a surgical abdominal emergency. Preventing infarction is the aim of a prompt surgery that can preserve the spleen and then proceed to splenopexy. We report a rare case of torsion of a wandering spleen associated with a dolichosigmoïd.

Wandering spleen is a rare condition characterized by the absence or underdevelopment of one or all of the ligaments that hold the spleen in its normal position in the left upper quadrant of the abdomen.[ 1 ] It is an uncommon clinical entity. It mainly affects children, who make up one third of all cases[ 2 ] with a female predominance after the age of one. At adult age it most frequently affects women of reproductive age, in whom acquired laxity of the splenic ligaments is usually the cause.[ 2 ] The clinical presentation of wandering spleen is variable, but the main symptom is abdominal pain. Its major complication is acute torsion with subsequent infarct, which is a potentially fatal emergency. We report a case of torsion of a wandering spleen associated with a dolichomegasigmoïd.

CASE REPORT

A 27-year-old woman presented to the emergency department after three days of abdominal pain, vomiting and constipation without fever. She had a recurrent constipation but no history of recurrent abdominal pain, abdominal mass, or trauma. On physical examination, abdominal distension was noted. There was a moderate diffuse abdominal tenderness more pronounced on the left side. Abdominal radiography showed an important colon distention especially at the upper left quadrant without air fluid levels [ Figure 1 ]. An abdominal ultrasonography showed a “whirl” image beside a spleen of ectopic position with homogenous echo texture [ Figure 2 ]. Computed tomography (CT) revealed a colonic distention, especially of the sigmoid and an abnormal position of the spleen at the left lower quadrant without any sign of spleen ischemia [ Figure 3 ]. The patient underwent laparotomy. Her spleen was in an ectopic position. It was rounded by a large and long left colon [ Figure 4 ]; there was no sustentaculum lieni, nor any of the spleen ligaments. The spleen pedicle was twisted without any sign of ischemia [ Figure 5 ]. Splenopexy was performed by the fixation of the spleen pedicle to the posteroparietal peritomeum. We used separated sutures with vicryl ® 0 prepared on the upper and lower borders of the pedicle before the spleen replacement in its quadrant, which were knotted at the end; sigmoidectomy and colorectal anastomosis were performed. The patient recovery was uneventful. She was discharged on the sixth day.

Abdominal radiography showed an important colon distention at the upper left quadrant without air fluid levels

Ultrasonography image demonstrated a whorl of concentric vessels in the region of splenic hilum. Note a spleen of ectopic position

Contrast enhanced abdominal CT in axial (a, b) and sagittal views (c, d) showed spleen vessels and surrounding fat forming a whirled appearance (arrows) at the spleen (star) hilum. The spleen is located below the level of the left kidney

Dolichosigmoid associated to the wandering spleen

Volvulus of the wandering spleen

Wandering spleen is defined as mobile spleen that is attached only by an elongated vascular pedicle, allowing it to migrate to any part of the abdomen or pelvis. It is a result of congenital anomalies in the development of the dorsal mesogastrium and the absence or malformation of normal splenic suspensory ligaments.[ 1 , 3 ] The splenic ligaments include the gastrolienal and lienorenal ligaments. The former attaches the spleen to the greater curvature of the stomach, whereas the latter attaches the spleen to the posterior abdominal wall, both ligaments attach to the hilum of the spleen medially. The phrenicocolic ligament supports the spleen inferiorly.[ 3 ]

However, acquired anomalies have been described and are attributed to laxity of the ligaments due to weakness of the abdominal wall, multiple pregnancies, hormonal changes or increase in size in the spleen.[ 4 ] Both congenital and acquired conditions result in a long pedicle, which is predisposed to torsion. The splenic vessels course within the pedicle, and therefore, torsion of the pedicle results in partial or complete infarct of the spleen.

Patients with a wandering spleen may be asymptomatic, present with a movable mass in the abdomen, or have chronic or intermittent abdominal pain because of partial torsion and spontaneous detorsion of the spleen.[ 5 , 6 ] Torsion is the most common complication.[ 4 ] It usually presents as an acute abdominal problem. This makes the physical examination more difficult and preoperative diagnosis less accurate. Clinically, the diagnosis can be suspected when a firm, movable abdominal mass is felt with the typically described “notched border”. However splenic engorgement may hide the splenic notch.[ 7 , 8 ] Preoperative diagnosis of wandering spleen is rarely suggested, based on clinical findings alone, because of nonspecific symptoms. Therefore, imaging plays a major role in establishing the diagnosis,[ 6 , 8 ] plain radiography and barium studies showed medial or superior displacement with extrinsic impression of the splenic flexure of colon along with a soft tissue mass in an unusual site corresponding to the wandering spleen[ 5 ] but are non-specific.

Sonography showed the characteristic comma-shaped spleen in an ectopic position and the lack of splenic tissue in the left upper quadrant. Duplex Doppler color flow evaluation, provided optimal visualization of the organ and assessment of vascular supply.[ 8 ] However, sonography can often be hampered by bowel gas. Angiography can also provide definite evidence of splenic torsion and ectopic splenic location, showing a tapered and abruptly twisted distal splenic artery at the point of torsion, but it is invasive and not essential for diagnostic purposes.[ 1 , 6 ]

Computed tomography is the preferred study for diagnosing a wandering spleen when torsion is suspected clinically or on other imaging studies. The CT manifestations included: (I) absence of the spleen anterior to the left kidney and posterior to the stomach, (II) a lower abdominal or pelvic mass with homogenous or heterogenous splenic parenchyma and an attenuation value less than that of normal splenic tissue, (III) whorled appearance of splenic vessels and surrounding fat only, and (IV) secondary findings such as ascites and necrosis of the pancreatic tail.[ 5 , 7 , 9 ]

However, it is the whorled appearance of the splenic vessels and surrounding fat at the splenic hilum that is considered as specific of torsion of a wandering spleen.[ 10 ] This sign was shown by the CT scan of the patient of this case. Until recently, splenectomy has been performed for wandering spleen[ 11 , 12 ] though several authors had advocated splenopexy earlier. Stringel et al .[ 4 ] fixed the spleen via its pedicle. Maxwell-Armstrong et al .[ 13 ] fixed it by omentum. Caracciolo et al .[ 14 ] and Peitgen et al .[ 15 ] used transposition of the colonic flexure and gastrocolic ligament for splenopexy. Allen and Andrews[ 16 ] sutured a basket of Dexon® mesh around the spleen, whereas Seashore and McIntosh,[ 17 ] van der Staak and Festen,[ 18 ] and Steinberg et al .[ 19 ] dissected a posterolateral retroperitoneal pouch during laparotomy. Actually, laparoscopic splenopexy is an easy alternative to laparotomy. The laparoscopic approaches reported[ 18 , 20 ] have used sacks and slings of Dexon® or Vicryl® mesh for fixation or an autologous peritoneal pouch in the posterolateral abdominal wall permitting to avoid the risk of infection of the mesh. The latest technique seems to have the best results according to the satisfaction of the patients and the esthetic appearance.[ 21 ]

In the present case, the spleen was fixed by its pedicle using a technique inspired by the one described by stringel.[ 4 ] In the stringel technique, the spleen was repositioned in the splenic fossa in the left upper quadrant. Two stabilizing continuous sutures of 3/0 silk were inserted running from the upper and lower ends of the hilum of the spleen to the posteroparietal peritoneum. These sutures appeared to provide enough fixation of the spleen to prevent torsion.[ 4 ]

The splenic torsion is sometimes associated with other manifestations like gastric or pancreatic tail volvulus.[ 22 , 23 ] The only colonic manifestations reported is obstruction by splenic flexure volvulus.[ 24 , 25 ] Dolichosigmoid associated with a wandering spleen seems to be reported for the first time in our case.

The torsion of a wandering spleen is a rare abdominal emergency. Its diagnosis should be made in prompt time to prevent infarction of the spleen. Splenopexy by means of the extraperitoneal pocket creation appears to allow anatomic placement of the spleen along with the protection of the rib cage without the employment of biomaterials. Splenectomy should be performed only in patients with splenic torsion in whom massive infarction and thrombosis of the splenic vessels has occurred.

Source of Support: Nil

Conflict of Interest: None declared.