Wandering spleen: a medical enigma, its natural history and rationalization

A painful twist: Wandering spleen with torsion and infarction: A case report

INTRODUCTION

Wandering spleen is a rare condition characterized by abnormal spleen mobility due to defects in its supporting ligaments. Delayed management can lead to severe complications such as torsion and infarction, making early diagnosis and surgical intervention crucial for preventing adverse outcomes.

CASE PRESENTATION

A 16-year-old girl presented with recurrent episodes of severe left hypochondrial pain, which worsened over six months, accompanied by occasional vomiting. Physical examination revealed a tender, palpable spleen extending from the left hypochondrium to the left iliac fossa. Imaging studies, including abdominal ultrasound and contrast-enhanced CT scan, revealed an enlarged spleen with signs of pedicle torsion and infarction, confirming a diagnosis of wandering spleen with vascular compromise. An emergency splenectomy was performed, revealing significant splenic enlargement with torsion and infarction, with no ligamentous attachments. The patient recovered uneventfully and received a pneumococcal vaccine along with long-term antibiotic prophylaxis prior to discharge.

DISCUSSION

Wandering spleen often presents with nonspecific symptoms, leading to misdiagnosis or delayed treatment. Diagnostic imaging is essential for accurate identification. Management typically involves surgery, with splenopexy preferred when feasible and splenectomy reserved for cases with complications.

CONCLUSION

Wandering spleen, though rare, requires prompt recognition and management to prevent complications like torsion and infarction.

Torsion of the wandering spleen with intestinal obstruction

Wandering spleen is a relatively rare condition and may be complicated by intestinal obstruction or abnormal intestinal rotation. Herein, we report a case where these three conditions appeared concomitantly. An 18-year-old woman with an intellectual disability was admitted to the hospital because of vomiting and fever. The patient's abdomen was distended. Computed tomography revealed a dilated small intestine, a swollen spleen located in the lower abdomen, as well as twisting and swirling of the splenic artery and vein. The patient was diagnosed with torsion of the wandering spleen and emergency surgery was performed. The vascular pedicle was found to be rotated 900° clockwise, and a markedly enlarged spleen was observed in the lower abdomen. When the splenic torsion was released, the pulsation of the splenic artery was well palpated, suggesting that the spleen could be preserved. Additionally, the sigmoid colon to the cecum was not fixed to the retroperitoneum. Dilatation of the small intestine was observed, but there were no findings of intestinal tract necrosis. Splenic torsion is part of the differential diagnosis for acute abdomen. Familiarity with embryology and anatomy is necessary to select the appropriate surgical technique.

Wandering spleen with torsion causing an acute abdomen: A case report

INTRODUCTION AND IMPORTANCE

Wandering spleen, also known as ectopic spleen, is an uncommon disorder in which the spleen's anatomical location differs from its fixed position in the abdomen's left upper quadrant. The etiology is either congenital or acquired, possibly leading to torsion and splenic infarction. It affects children and young adults, especially childbearing-age women. Patients affected by this condition may present with nonspecific symptoms requiring a high index of suspicion. Given the nonspecific clinical symptoms and the potential complications associated with wandering spleen, computed tomography scans provide a crucial means for proper diagnosis.

CASE PRESENTATION

A 38-year-old female patient presented with worsening abdominal pain of one-week duration. The pain was more localized to the left hemi abdomen but later she claimed that it became diffuse. She had associated vomiting of ingested matter and loss of appetite. She had a similar complaint of abdominal pain for the last year. Up on examination, she looked acutely sick. Abdominal examination showed a flat abdomen moved with respiration; a big intra-abdominal mass was tender; it was freely mobile in all directions; with no sign of fluid collection. A CT scan of the abdomen suggested an ectopic spleen with splenic torsion. Intraoperative findings revealed an infarcted wandering spleen. An emergency splenectomy was performed. The patient was discharged on the third postoperative day and had an uneventful postoperative recovery.

CLINICAL DISCUSSION

If a normal spleen is not identified in the left upper quadrant, a search for ectopic splenic tissue should ensue. If the patient has not had a prior surgical splenectomy, some possible explanations include an ectopic or "wandering" spleen. This case was an infarcted wandering spleen caused by abnormal ligamentous attachments.

CONCLUSION

Wandering spleen with torsion poses a great diagnostic challenge for acute abdomen due to the rarity of its occurrence and non-specific presentations. A high index of suspicion is the key to early diagnosis and timely intervention is required to improve treatment outcomes.

Delayed presentation of splenic laceration in a postpartum patient: a case of wandering spleen

Wandering spleen (WS) is a rare condition where the spleen is abnormally mobile due to lax or poorly developed ligaments, leading to complications like torsion and laceration after trauma. We describe a case of a 31-year-old postpartum female who presented with severe abdominal pain following blunt trauma. Diagnostics showed an enlarged, ectopic spleen, and significant hematoma. Surgical exploration revealed a 10-cm splenic laceration, necessitating a splenectomy due to extensive blood loss and organ damage. This case highlights the challenges of diagnosing WS, particularly in postpartum patients with increased ligamentous laxity, emphasizing the need for vigilant monitoring and potentially preventive surgical measures to manage this complex condition effectively.

[Torsion of the wandering spleen in childhood - report of 3 cases]

A vándorlép gyermekkorban ritkán előforduló fejlődési rendellenesség, melynek lényege, hogy a lépet a has bal felső kvadránsában rögzítő szalagok vagy lazák, vagy hiányoznak. Ez az anatómiai környezet kedvez a lépcsavarodásnak, mely a leggyakoribb szövődmény vándorlép esetén. Ammenyiben vándorlép igazolódik, műtétre van szükség. Két műtéti stratégia közül választhatunk: megtartjuk és fixáljuk, vagy egyértelmű infarktus esetén eltávolítjuk a lépet. A szerzők egy 16 éves periódust (2004–2020) tekintenek át, amelynek során két intézetben három gyermeket kezeltek lépcsavarodás miatt. A hasi panaszok kezdetétől 12–48 órán belül történt hasi ultrahangvizsgálat. A gyermeksebészeti vizsgálatok előtt a gyermekek székrekedés gyanúja miatt mindhárom esetben béltisztító kezelést kaptak, mivel az első észlelők a vándorlépet kitapintva skybalának tartották. A képalkotó vizsgálatok ectopiás helyen lévő lépet igazoltak, és felvetették a lépcsavarodás gyanúját. Nyitott műtét során mindhárom esetben lépmegtartó műtét történt. Posztoperatív szövődmény nem alakult ki. A megtartott lépek életképességét illetően nyomon követéses vizsgálatok történtek. Orv Hetil. 2024; 165(22): 866–871.

Torsion of a wandering spleen in a pregnant patient presented with acute abdomen: A case report

INTRODUCTION AND IMPORTANCE

Wandering spleen may result in torsion or splenomegaly, which causes symptoms such as intestinal obstruction, nausea, vomiting, and swelling in the abdomen. There are few reports of wandering spleen torsion in pregnant mothers. The diagnosis and presentation of splenic torsion is variable and challenging during pregnancy. Herein, we present a case of torsion of a wandering spleen in a 30-year-old pregnant patient.

CASE PRESENTATION

A 30-year-old female presented with a sudden onset of abdominal pain of three days' duration. There was lower abdominal mass and tenderness. Intraoperative findings revealed enlarged spleen located over the lower abdominal cavity with six times clockwise rotation of the splenic pedicle over itself. A splenectomy was performed. The patient was discharged on the 7th postoperative day and had an uneventful postoperative recovery.

CLINICAL DISCUSSION

Patient presentation could be asymptomatic, chronic left abdominal pain or symptoms and signs of complication. The most common complication of wandering spleen is torsion (Abell, n.d.). Splenic torsion is evidenced by mucosal bleeding, hematemesis, anemia or thrombocytopenia in our patient platelets level was 111,000 cells/μl which suggests vascular thrombosis. The other peculiarity during pregnancy is torsion of the spleen have higher mortality reaching up to 41 % (Lewis and Wolskel, 1962) which may be from delay in diagnosis or misdiagnosis.

CONCLUSION

There is high mortality associated with splenic torsion in pregnant patient reported in the literature. One of the explanations is misdiagnosis and delay in diagnosis of torsion of a wandering spleen in a pregnant patient.

Torsion of wandering spleen after Fontan operation in a patient with situs inversus: a rare complication

Torsion of wandering spleen after the Fontan operation with situs inversus is rare.Here, we report the case of a 6-year-old girl with a single ventricle and complete situs inversus who developed torsion of wandering spleen due to splenomegaly caused by post-operative haemodynamics of the Fontan operation. The platelet count was suggested to be useful in predicting splenic torsion.

A wandering spleen with 720° torsion and persistent ascending and descending mesocolon in a 5-year-old Syrian male: A case report

INTRODUCTION AND IMPORTANCE

The spleen is normally found in the left hypochondrium and it is fixed in its place by numerous suspensory ligaments. When the ligaments are elongated or abnormally developed, it causes a rare medical condition called Wandering spleen. A persistent ascending and descending mesocolon is also a congenital anomaly, resulting from the failure of fusion of the primitive dorsal mesocolon.

CASE PRESENTATION

Herein, a 5-year-old male child with sudden and acute onset of abdominal pain, constipation, nausea, tachycardia, and low urine output, imaging and blood tests revealed evidence of intestinal obstruction and normocytic anemia and neutrophilia. A laparotomy revealed persistent ascending and descending mesocolon, with a torsioned vascular pedicle of the spleen, resulting in splenomegaly and infarction. The surgeon successfully derotated the torsioned pedicle and performed a splenectomy. The patient had an uneventful postoperative course and was discharged without complications.

CLINICAL DISCUSSION

This case could be asymptomatic and the diagnosis is incidental or it could be presented with ambiguous symptoms. The differential diagnosis of WS varies according to the clinical presentation and the associated complication. For instance, in the case of WS torsion and acute presentation, the differential diagnosis is ovarian torsion, acute appendicitis, and intestinal obstruction. Currently, surgery is the only suggested treatment option even in asymptomatic patients as well.

CONCLUSION

This case of a Wandering Spleen is associated with a persistent ascending and descending mesocolon, suggesting that there may be certain risk factors. Therefore, we suggest making more research about wandering spleen in association with persistent mesocolon.

Acute Gastric Volvulus With Wandering Spleen in a Two-Year-Old Child: A Rare Association

Gastric volvulus is a rare clinical condition characterized by a pathological rotation of the stomach greater than 180º around its axis. The wandering spleen is also an exceptional clinical entity characterized by the absence or laxity of splenic ligaments which lead to splenic mobility in the abdominal cavity from its normal anatomical site. Wandering spleen and gastric volvulus association is unusual. Both can be life-threatening if left untreated. We herein present a rare, unusual association of mesenteroaxial gastric volvulus with wandering spleen in a two-year-old child and interpret the radiological findings to ensure correct and early diagnosis.

Wandering liver, spleen, and kidney: what the radiologist needs to know

The wandering spleen, wandering liver, and wandering kidney are rare diagnoses that can be asymptomatic or are associated with nonspecific symptoms, making the clinical diagnosis elusive. In addition, given the small number of cases, these conditions are not well understood. Major complications of wandering spleen result from torsion of the vascular pedicle with resultant ischemia, physiologic dysfunction, and/or infarction. Wandering liver is commonly associated with bowel obstruction, particularly colonic volvulus, with very rare reports of hepatic ischemia or infarct. Wandering kidneys are not commonly associated with serious complications. In many cases, the wandering spleen, liver or kidney can be found in their anatomic position on static imaging and are only diagnosed during ultrasound or with serial radiographic or cross-sectional imaging with different patient positioning, or with prior studies demonstrating different locations of the involved organ. Treatment approaches for uncomplicated wandering spleen, liver, or kidney include watchful waiting and splenopexy, hepatopexy, or nephropexy, respectively. Complicated wandering spleens are treated with splenectomy. Given the variable clinical presentation of these conditions, imaging plays a pivotal role in diagnosing these rare and often incidentally discovered phenomena.

Surgical Management of a Volvulus of a Wandering Spleen Associated with a Volvulus of the Small Intestine

Introduction

A wandering spleen is a rare anatomical condition characterized by a free-floating splenic tissue that is not located in its normal position in the left upper quadrant. This condition is usually asymptomatic but can also manifest itself with volvulus of the spleen and consequent infarction and necrosis of the parenchyma, requiring an urgent surgical management. Additionally, a wandering spleen can be associated with other contemporaneous anatomical anomalies. Case Presentation. We report a case of a 21-year-old woman, admitted to our hospital for intense abdominal pain and vomiting. A CT scan revealed a wandering spleen in the mesogastric area with the spleen torted on its axis, associated with a volvulus of the small intestine. Abdominal exploration revealed a macroscopically normal free-floating spleen attached to an abnormally long vascular pedicle. The management of the wandering spleen was conservative, and a splenopexy was performed.

Conclusions

The torsion of the wandering spleen constitutes an infrequent but life-threatening abdominal emergency. The diagnosis of the wandering spleen is frequently challenging since clinical findings are usually not specific. Imaging such as computed tomography scan plays an important role in the differential diagnosis pathway. Treatment should be planned according to the splenic parenchyma conditions. Splenectomy is indicated when massive infarction and thrombosis of splenic vessels have occurred. When splenic parenchyma is not compromised, it is preferred to perform a conservative surgical technique, such as splenopexy, in order to avoid postsplenectomy complications.

Wandering Spleen - A Possible Cause of Adrenal “Mass” - Case Report

Wandering spleen is a very rare clinical condition characterized by spleen absence in the normal anatomical location in the upper left quadrant of the abdomen and its presence at another location in the abdomen or pelvis. The ectopic spleen is extremely rare in children, where its increased mobility is the result of a congenital disturbance of the fixation for the anterior wall due to the absence or weakness of the supporting ligaments. Wandering spleen is usually asymptomatic, but its torsion is possible, as well as infarction or rupture which demand an urgent diagnosis and surgical treatment. The diagnosis of wandering spleen can easily be overlooked due to low incidence and insufficient clinical experience, which multiplies patient's risk from life-threatening conditions. We present a case of wandering spleen in an 11-year-old girl with acute abdominal pain, which after ultrasound examination raised suspicion on the right adrenal gland tumor. Additional diagnostics verified an ectopic spleen in the right adrenal box, after which the recommended preventive splenopexy was seriously considered. Due to the fixation of the vital spleen in the new position, but also the negative attitude of the parents towards the surgical intervention, clinical monitoring was selected, with exclusion of intense physical activity that carries the risk of traumatization of the spleen. As the girl has been in good health for over 3 years and without symptoms, we consider that the selection of conservative access although difficult, was correct. We hope that our experience in treating wandering spleen in girls will increase the number of valid facts about this rare condition.

Wandering Spleen: A Rare Case of an Adnexal Lesion

The wandering spleen (WS) is a rare condition in which the spleen is not found in its usual location in the left hypochondrium but is positioned in the lower abdomen or the pelvis. This is a case of a 21-year-old woman who presented with chronic, intermittent, and subtle pain in the left lower quadrant of her abdomen. After clinical examination and ultrasound evaluation, an adnexal lesion was detected in the left lumbar area, and no splenic tissue was found in the left hypochondrium. The wandering spleen should be included in the differential diagnosis when encountering a patient with non-typical or acute abdominal pain. Accurate diagnostic evaluation can be performed with low-cost imaging modalities such as Doppler ultrasound.

Successful treatment of floating splenic volvulus: Two case reports and a literature review

BACKGROUND

The floating spleen refers to the spleen moving away from the normal anatomical position to other parts of the abdominal cavity.

CASE SUMMARY

In this report, we describe two cases of torsion of floating spleen, which were successfully treated by laparoscopic partial splenectomy and retroperitoneal fixation of the residual spleen. The clinical characteristics of previously reported cases are also discussed.

CONCLUSION

In conclusion, laparoscopic partial resection of splenic volvulus infarction and extraperitoneal fixation of residual spleen are safe and reliable.

Diagnosis, management and outcome of splenic torsion; a systematic review of published studies

INTRODUCTION

Splenic torsion is a rare condition but one that many surgeons will encounter once in their career. Management options are varied but due to the rarity of the condition there are no contemporary evidence-based summaries to inform a treating clinician. We aim to describe patterns of presentation and provide an evidence-based guide to the management.

METHODS

A PRISMA structured meta-analysis was conducted of all published cases of splenic torsion and a recent case added from our institution.

RESULTS

408 cases were identified between 1888 and 2021 and a single case added from our institution, 312 cases were sourced from case reports and 96 from 40 case series. 8% of patients had a co-existing congenital anomaly and 28% an identified risk factor for splenic torsion. 82% required emergency surgery. A preoperative diagnosis is becoming more common, reaching 80% in 2020's. While spleen conserving surgery is feasible using a variety of techniques. splenectomy was the definitive management for the majority (82%). On histopatholy no occult disease was identified and a significant number of resected spleens were potentially viable; 32% were reported to be normal or congested and 14% demonstrated only partial or focal necrosis.

DISCUSSION

Despite the significant publication bias implied by the methodology this is a large dataset in a rare condition. Splenic torsion frequently occurs in a premorbid population. The presence of a palpable mass in the context of abdominal pain should increase suspicion and trigger cross sectional imaging. Conservation of the spleen, using the techniques discussed, should be seriously considered.

Infarcted wandering spleen: A case report from Saudi Arabia

Spleen is normally positioned in the left upper quadrant. Abnormal location where it is not found in its normal anatomical position is called wandering spleen (WS). Wandering spleen is a rare medical condition that occurs due to developmental abnormality or acquired laxity of the ligaments that hold the spleen in its normal anatomical position. It affects children and young adults, especially childbearing age women. Patients affected with this condition may present with nonspecific symptoms requiring a high index of suspicion. Here, we are presenting a 20-year-old female known to have WS ended up with infarcted WS requiring emergency splenectomy.

Torsion of the wandering spleen as an abdominal emergency: a case report

Background

Wandering spleen is a rare clinical entity with a less than 0.2% reporting incidence rate. In this case, the spleen is present abnormally in the abdominal or pelvic cavity instead of its normal anatomical location. The aetiology is either congenital or acquired. The condition is caused by the absence or maldevelopment of the spleen's suspensory ligaments, which holds the spleen static in the left hypochondrium.

Case presentation

A 27-year-old female patient presented to the emergency department with complaints of abdominal pain, fever, nausea, vomiting, and constipation for three days. A palpable movable mass was found during the physical examination, and torsion of the wandering spleen’s pedicle was confirmed by CT scan. Open splenectomy was performed, and the patient was recovered uneventfully.

Conclusion

Even though ectopic spleen is a rare disease, clinicians should be aware of its incidence. Early diagnosis in the case of an acute abdomen is vital for the preservation of the spleen. Patients presented with acute abdomen and absence of splenic shadow under left hemidiaphragm should be suspected, and further radiological investigation will confirm the diagnosis. Surgery is the gold standard for wandering spleen with either splenopexy or splenectomy, depending on the spleen's condition during surgery.

'Wandering spleen with acute torsion' : a rare indication for splenectomy in an adult, complicated by postoperative splanchnic venous thrombosis and intestinal gangrene

Wandering spleen (WS) is a hypermobile spleen that, due to the laxity of its ligaments, is prone to torsion. We report a case of a 45-year-old multiparous woman who presented with acute abdominal pain and a tender palpable mass. A contrast-enhanced computed tomography scan of the abdomen showed a WS with torsion. She underwent an emergency splenectomy and was discharged after an uneventful recovery. She was readmitted with splanchnic venous thrombosis and was managed with therapeutic low-molecular-weight heparin (LMWH) and discharged. Twenty days later, she presented with new-onset abdominal pain. She had not complied with LMWH as advised. The thrombosis had progressed, leading to small bowel gangrene, requiring resection and a stoma. Due to frequent metabolic disturbances, an early reversal of stoma was performed. She was lost to follow-up thereafter. This case highlights a rare indication for emergency splenectomy and one of its major postoperative complications.

Surgical Approach of Wandering Spleen in Infants and Children: A Systematic Review

Introduction: Splenopexy has been proposed as the treatment of choice in case of wandering spleen (WS). We report our experience and review the current literature focusing on surgical management and outcomes of children affected by WS. Materials and Methods: Data regarding demographics, clinical manifestations, diagnosis, and treatment of children treated for WS at our Institution were analyzed. Systematic review was registered on Prospero (CRD42018089971). Scientific databases were searched using defined keywords. Articles were selected using predefined exclusion and inclusion criteria. Analysis was conducted adding our center's cases. Results: One hundred sixty-six articles were included in the review, 197 cases were analyzed, 3 of which unpublished. Female/male ratio was 1.5:1 and median age at diagnosis was 8 years. Most frequent clinical manifestation was isolated abdominal pain (42.6%). Torsion of splenic pedicle was diagnosed in 56.3%. Among surgical procedures, 39% underwent splenopexy and 54.8% underwent splenectomy. In case of splenopexy, the most commonly used techniques were using of a mesh (45.5%) or creation of a retroperitoneal pouch (30.9%). In 48.2% of splenopexies, minimally invasive surgery (MIS) was used. Splenopexy was effective in 94.8% (88% considering only cases with a spleen torsion). Conclusion: WS is a rare condition potentially leading to torsion of the spleen. This entity has to be kept in mind as a differential diagnosis in case of abdominal pain. Splenopexy should be the treatment of choice; its success rate in terms of preserved spleens can be affected by the presence of a torted organ. Retroperitoneal pouch or mesh fixation are the most preferred techniques. Authors recommend MIS approach.

Case Report: Conservative Non-operative Management of a Neonate With Torted Wandering Spleen

BACKGROUND

The management of wandering spleen (WS) with torsion, a rare pathological condition, is currently unclear. Most patients with this disorder are treated with surgical interventions, such as splenectomy or splenopexy.

CASE PRESENTATION

A newborn female presented with low hemoglobin (10.8 mg/L) and high total serum bilirubin (193 μmol/L) at 3 h of life. A palpable mass was observed during her physical examination, and a magnetic resonance imaging scan of the abdomen confirmed the presence of an infarcted WS with torsion. Upon conservative management with oral antibiotic prophylaxis, careful observation, and repeated follow-ups, the infant remained clinically stable. At 2 years of age, she had normal complete blood count, and a repeat technetium study revealed two splenunculi/splenules in the splenic bed.

CONCLUSION

Most patients with WS are treated surgically with splenectomy or splenopexy. Non-operative management may be a feasible treatment option in select cases with infarcted WS and may allow the natural process of autosplenectomy to occur.

[A case report of wandering spleen]

INTRODUCTION

Wandering spleen is a rare condition that occurs when there is an acquired or congenital hypelaxity of the suspensory ligaments of the spleen, resulting in its migration to any abdominal or pelvic position.

CASE REPORT

A 43-year-old woman presented with symptoms of acute abdominal pain. At physical examination, a splenomegaly was found in the left hypochondria, thereafter followed by a secondary migration of the lump to a periumbilical location. Computed tomography revealed a wandering spleen with vascular pedicle torsion. Splenopexia was perfomed.

CONCLUSION

A wandering spleen is most frequently observed in children and young women. This rare diagnosis should be considered facing a recurrent abdominal pain syndrome, a splenomegaly accompanied with pain, or a pelvic lump. A wandering spleen may lead to torsion of the vascular pedicle of the spleen, a chronic volvulus with portal hypertension, or even a splenic infarction. The diagnosis is performed by computed tomography. Wandering spleen is treated surgically, by splenopexy or splenectomy.

From sadness to stiffness: the spleen's progress

The spleen is a lymphoid organ that has been poorly studied compared to other solid organs, probably because it has been considered a useless and unnecessary part of the body. For many centuries it has been considered a mysterious organ with uncertain functions. The first descriptions of the spleen date back to ancient ages. The spleen has been considered as a reservoir of liquids, strictly linked to stomach digestion, and in different cultures, it has been linked to melancholy and sadness due to the accumulation of black bile (humoral doctrine). A detailed anatomic description was first made by Vesalius during the Renaissance, and further implemented with the description of its microscopic structure by Marcello Malpighi in the seventeenth century. The first case reports regarding spleen functions and pathology regarded common causes of splenomegaly, such as malaria infection, and traumatic rupture. At the beginning of the last century, the pivotal concepts of hypo- and hypersplenism were introduced, along with the cumulating evidence of the relation between spleen removal and increased susceptibility to infections and thromboembolism. The study of hyposplenic states, which occur much more commonly than originally thought in many immune-mediated disorders, has rapidly increased after the validation of a simple method for assessing spleen function, namely pitted red cell count. In recent years, spleen morphology, in particular spleen stiffness, has been proposed as a marker of portal hypertension. In this paper, we retrace the fundamental steps of the discovery of the functions of the spleen.

Left lower quadrant pain: an unlikely diagnosis in a case of acute abdomen

Splenic infarct is an incredibly rare diagnosis for abdominal pain. One study involving two hospitals over ten years describes only 0.0037% of all hospital admissions presenting with splenic infarction. Our report describes a case of massive splenomegaly causing pain in a different location compared to the normal anatomical location of the spleen with an unexpected cause, lymphoma. High clinical suspicion for lymphoma as a cause of splenic infarction is critical because this disease can otherwise be clinically silent. This case emphasizes the importance of a thorough clinical workup and persistence in diagnostic pursuit.

Torsion of a wandering spleen as a cause of portal hypertension and mesenteric varices: a rare aetiology

A wandering spleen is a condition characterized by excessive splenic mobility due to the mal-development or the laxity of its ligaments that leads to migration from its normal anatomical location. This condition renders its long mobile vascular pedicle liable to torsion and occasional infarction. Herein, we report a case of a 27-year-old nulliparous woman who presented with acute abdominal pain and a tender right-sided pelvi-abdominal mass. CT scan of the abdomen and pelvis revealed a torted, infarcted wandering spleen with portal hypertension and mesenteric varices that mandated an emergency splenectomy. Although there are a few reported cases describing the association of wandering spleen with portal hypertension and fundal varices, cases of mesenteric varices are extremely rare. To the best of our knowledge, this case is considered the third reported case of a wandering spleen which was subsequently complicated by portal hypertension and mesenteric varices that was managed effectively with splenectomy.

Splenic torsion, a challenging diagnosis: Case report and review of literature

INTRODUCTION

Wandering spleen is an unusual condition characterized by hypermobility of the spleen. This is a rare clinical entity and it's more common in childhood under 1 year of age and in third decade of life. In this second peak, it's more frequent in females. Clinical manifestations can vary from asymptomatic to abdominal emergency. Treatment is often surgical.

PRESENTATION OF CASE

We presented a case report of splenic torsion from our hospital and a review of cases described in literature. This is a 40 year-old woman with complaints of upper abdominal pain associated with nausea and vomiting. A marked tenderness and a palpable abdominal mass on left hypochondrium were found as well as a slight increase in inflammatory parameters. A CT was performed and demonstrated findings compatible with splenic torsion. Surgery was performed doing laparoscopic splenectomy; Review of literature was made using the keyword combination: "wandering spleen". The research resulted in 451 articles.

DISCUSSION

The physical examination and CT are fundamental for diagnosis. Surgery was performed and laparoscopic splenectomy was made because infarcted spleen; about the review of literature, the majority of patients were female and the average age at the time of diagnosis was 25.2 years. 69.5% needed splenectomy and 78.6% of surgeries were laparotomic.

CONCLUSION

Splenic torsion is a rare but important differential diagnosis in patients presenting with acute abdomen. Diagnosis should be made promptly before development of life-threatening complications. Surgery is often necessary and splenopexy or splenectomy can be done.

The Great Pretender: Pediatric Wandering Spleen: Two Case Reports and Review of the Literature

Wandering spleen is a rare condition, typically not only due to embryological defects of the splenic ligaments, but also secondary to trauma and splenomegaly. The most common presentation is acute abdomen with a mobile abdominal mass or recurrent abdominal pain. However, the spleen may be temporary in its normal position, and patients could be asymptomatic. A familiarity, if present, strengthens the diagnostic suspect.Abdominal ultrasonography and computed tomography are the examination of choice, and the management is surgical.

Wandering spleen torsion-use of contrast-enhanced ultrasound

We report a case of torsion of a wandering spleen in an 18-year-old male patient who presented with acute abdominal pain and left lower quadrant mass. The patient was initially misdiagnosed at another institution. The patient came to our hospital for further investigation. Contrast-enhanced ultrasound was performed and showed a solid hypoechoic avascular mass, which was all that remained of the spleen, located under the left kidney. Based on the ultrasound findings, CT scan and MRI of the abdomen were performed to confirm the suspicion of torsion of a wandering spleen. To the best of our knowledge, there are no case reports describing the use of contrast-enhanced ultrasound for diagnosing torsion of a wandering spleen.

Acute gastric volvulus associated with wandering spleen in an adult treated laparoscopically after endoscopic reduction: a case report

A 43-year-old female was referred to our hospital for sudden onset of abdominal pain, fullness, and vomiting. Physical examination revealed abdominal distension with mild epigastric tenderness. Abdominal radiography showed massive gastric distension and plain computed tomography (CT) a markedly enlarged stomach filled with gas and fluid. A large volume of gastric contents was suctioned out via a nasogastric (NG) tube. Contrast-enhanced CT showed a grossly distended stomach with displacement of the antrum above the gastroesophageal junction, and the spleen was dislocated inferiorly. Upper gastrointestinal (GI) series showed the greater curvature to be elevated and the gastric fundus to be lower than normal. Acute mesenteroaxial gastric volvulus was diagnosed. GI endoscopy showed a distortion of the gastric anatomy with difficulty intubating the pylorus. Various endoscopic maneuvers were required to reposition the stomach, and the symptoms showed immediate and complete solution. GI fluoroscopy was performed 3 days later. Initially, most of the contrast medium accumulated in the fundus, which was drawn prominently downward, and then began flowing into the duodenum with anteflexion. Elective laparoscopic surgery was performed 1 month later. The stomach was in its normal position, but the fundus was folded posteroinferiorly. The spleen attached to the fundus was normal in size but extremely mobile. We diagnosed a wandering spleen based on the operative findings. Gastropexy was performed for the treatment of gastric volvulus and wandering spleen. The patient remained asymptomatic, and there was no evidence of recurrence during a follow-up period of 24 months. This report describes a rare adult case of acute gastric volvulus associated with wandering spleen. Because delay in treatment can result in lethal complications, it is critical to provide a prompt and correct diagnosis and surgical intervention. We advocate laparoscopic surgery after endoscopic reduction because it is a safe and effective procedure with lower invasiveness.

Laparoscopic transperitoneal left adrenalectomy and wandering spleen risk

Background and Objectives:

Laparoscopic transperitoneal left adrenalectomy (LTLA) has become the standard treatment for adrenal masses <6 cm. LTLA involves the dissection of splenic suspensory ligaments, which replicates their congenital absence or weakening, present in cases of wandering spleen (WS). WS is a rare condition in which the spleen migrates from the left upper quadrant to a more caudal location in the abdomen. A unique case of WS after LTLA was described by Corcione et al. In this prospective study, we investigated the possibility of WS as a consequence of LTLA.

Methods:

Twenty-four patients, 8 men and 16 women, who underwent LTLA with the dissection of splenoparietal and splenorenal ligaments were selected.

Results:

Clinical and ultrasonographic follow-up showed no evidence of postoperative WS.

Conclusions:

In the literature, WS is not commonly reported as a postoperative complication of LTLA. In effect, especially in the case of small adrenal masses, the spleen's repositioning in its seat is autonomous. However, the alarming possibility of WS should not be ignored, especially in the case of extensive dissection of the left colic flexure. It would be useful for other authors to signal this complication, so that different approaches and consequent results may be compared.

Evaluating Patients with Left Upper Quadrant Pain

Imaging plays a major role in the evaluation of patients who present to the emergency department with acute left upper quadrant (LUQ) pain. Multidetector computed tomography is currently the primary modality used for imaging these patients. The peritoneal reflections, subperitoneal compartment, and peritoneal spaces of the LUQ are key anatomic features in understanding the imaging appearance of acute diseases in this area. Diseases of the stomach, spleen, pancreas, and splenic flexure are encountered in patients with acute LUQ pain. Optimization of the imaging protocol is vital for accurate diagnosis and characterization of these diseases in the acute setting.

Wandering spleen with chronic torsion in a patient with thalassaemia

Wandering spleen or splenoptosis is an uncommon entity and often an asymptomatic finding of acute abdomen in the emergency department. A high index of suspicion for splenic torsion is required, particularly in patients with known splenomegaly, as this condition could potentially lead to splenic infarction. Recognition of this condition can help avoid potential confusion with acute abdomen of other aetiologies. Herein, we present a unique case of wandering spleen with chronic torsion, which, to the best of our knowledge, has never been described in an elderly patient with haemoglobin H thalassaemia. We also review the literature for the aetiology and pathogenesis of wandering spleen, and discuss the relevant diagnostic modalities and treatment options.

Single-incision laparoscopic splenectomy and splenic autotransplantation for an enlarged wandering spleen with torsion

A wandering spleen is a rare condition in which the spleen is not located in the left upper quadrant, but instead is found in the lower abdomen or in the pelvic region because of the laxity of the peritoneal attachments. The unusually long pedicle is susceptible to twisting, which can lead to ischemia, and eventually to necrosis. We herein report a case of an enlarged wandering spleen with torsion, successfully treated by single-incision laparoscopic splenectomy and autotransplantation. The transplanted splenic tissues could be identified on a spleen scintigram obtained 3 months after the surgery. Howell-Jolly bodies were not observed in blood specimens. This procedure is able to prevent an overwhelming postsplenectomy infection, and leads to satisfactory cosmetic results.

Ectopic spleen: An easily identifiable but commonly undiagnosed entity until manifestation of complications

INTRODUCTION

Ectopic spleen is an uncommon clinical entity as splenectomy for treatment of ectopic spleens accounts for less than 0.25% of splenectomies. The most common age of presentation is childhood especially under 1 year of age followed by the third decade of life.

PRESENTATION OF CASE

The present report refers to a patient with torsion of a pelvic spleen treated with splenectomy. The patient exhibited a period of vague intermittent lower abdominal pain lasted 65 days followed by a period of constant left lower quadrant pain of increasing severity lasted 6 days. On the first 65 days, vague pain was attributed to progressive torsion of the spleen which resulted in venous congestion. On the last 6 days, exacerbation of pain was attributed to irreducible torsion, infraction of the arterial supply, acute ischemia, strangulation and rupture of the gangrenous spleen. Diagnosis was made by CT which revealed absence of the spleen in its normal position, a homogeneous pelvic mass with no contrast enhancement, free blood in the peritoneal cavity, and confirmed by laparotomy.

DISCUSSION

Clinical manifestations of ectopic spleen vary from asymptomatic to abdominal emergency. Symptoms are most commonly attributed to complications related to torsion. Operative management, including splenopexy or splenectomy, is the treatment of choice in uncomplicated and complicated cases because conservative treatment of an asymptomatic ectopic spleen is associated with a complication rate of 65%.

CONCLUSION

Although an ectopic spleen can be easily identified on clinical examination, it is commonly misdiagnosed until the manifestation of complications in adulthood.

Salvage splenopexy for torsion of wandering spleen in a child

The wandering spleen is a rare condition characterized by the absence or underdevelopment of one or all of the splenic suspensory ligaments that resulting in increased splenic mobility and rarely torsion. Preventing infarction is the aim of a prompt surgery by splenopexy. We report a case of salvage splenopexy in torsion of a wandering spleen in a three year old girl presented with severe abdominal pain for three days.

Acute torsion of a wandering spleen in a post-partum female: A case report

INTRODUCTION

Wandering spleen is a rare condition characterized by ectopic position of the spleen due to the absence or laxity of peritoneal ligaments that hold the organ within the left upper quadrant. Lower abdomen and pelvis are the most common locations of the wandering spleen. The disorder usually remains asymptomatic.

PRESENTATION OF CASE

We present a case of acute abdomen due to torsion of a wandering spleen in a primiparus, healthy female shortly after delivery. Diagnosis was based on ultrasonography and computed tomography and was confirmed later on surgery. Total splenectomy was performed successfully.

DISCUSSION

The rarity of the condition and the nonspecific clinical symptoms and signs make prompt diagnosis challenging.

CONCLUSION

Prompt recognition and intervention are necessary in order to minimize the risk of complications. For this reason physicians have to include the condition in the differential diagnosis of acute abdominal pain especially when they encounter females in a pregnancy or post-natal period.