Pelvic pain in the presence of wandering spleen

The imaging features of ectopic spleen: which modality is more consistent? A cases series report and literature reviews

Ectopic spleen (ES) is a rare condition. It is difficult to diagnose with conventional imaging modalities. In this case series, we presented the imaging features of three misdiagnosed ES cases in our hospital and previously reported cases to compare the consistency of enhancement patterns among different imaging modalities with varied phases. Finally, 22 cases were reviewed. We determined that variable arterial phase enhancement and persistent enhancement throughout the portal and delayed phases are present in contrast-enhanced ultrasound (CEUS) imaging of the ES and found the arterial phase of CEUS had the highest consistency compared with computerized tomography (CT) and magnetic resonance imaging (MRI).

Wandering spleen with splenic torsion in a toddler: A case report and literature review

RATIONALE

Wandering spleen (WS) is a rare clinical entity characterized by splenic hypermobility caused by absent or abnormal laxity of the suspensory ligaments, which fix the spleen in its normal position. Due to abnormal attachment, the spleen is predisposed to torsion and a series of complications. Pediatric WS is mostly reported in children aged <10 years, especially among infants aged <1 year; it is uncommon among toddlers between 1 and 3 years. To the authors' knowledge, only seven cases of WS have been described previously. Herein, we present the case of a 3-year-old toddler with WS and splenic torsion.

PATIENT CONCERNS

A 3-year-old boy was presented to the pediatric emergency room with a 2-day history of abdominal pain and vomiting. The ultrasonographic examination revealed a mass in the left upper abdomen cavity and absence of spleen in its normal position. Computed tomography showed an enlarged displaced spleen occupying the left abdomen cavity with an elongated splenic vascular pedicle (whirl sign), suggesting splenic torsion.

DIAGNOSES

The patient was diagnosed that had WS and splenomegaly, with or without complications due to splenic torsion.

INTERVENTIONS

The patient underwent emergency laparotomy and splenectomy due to nonviability after detorsion.

OUTCOMES

The postoperative course was uneventful, and the patient was discharged on the 7th day postoperatively without complications. The patient had favorable outcome over a 1-year follow-up.

LESSONS

Herein, we reported the case of a toddler with WS with splenic torsion. Moreover, after reviewing relevant studies in literature, we presented our findings on the diagnosis and treatment of toddlers with WS. Toddlers with WS are characterized by acute abdominal pain, unclear history description, examination restrictions, and high rates of life-threatening complications. High level of suspicion, careful physical examination, detailed history collection, and objective investigation are crucial in the management of toddlers with WS.

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.