Wandering spleen--the radiological and clinical spectrum

Torsion of spleen and portal hypertension: Pathophysiology and clinical implications

The displacement of spleen from its normal location to other places is known as wandering spleen (WS) and is a rare disease. The repeated torsion of WS is due to the presence of long pedicle and absence/laxity of anchoring ligaments. A WS is an extremely rare cause of left-sided portal hypertension (PHT) and severe gastric variceal bleeding. Left-sided PHT usually occurs as a result of splenic vein occlusion caused by splenic torsion, extrinsic compression of the splenic pedicle by enlarged spleen, and splenic vein thrombosis. There is a paucity of data on WS-related PHT, and these data are mostly in the form of case reports. In this review, we have analyzed the data of 20 reported cases of WS-related PHT. The mechanisms of pathogenesis, clinico-demographic profile, and clinical implications are described in this article. The majority of patients were diagnosed in the second to third decade of life (mean age: 26 years), with a strong female preponderance (M:F = 1:9). Eleven of the 20 WS patients with left-sided PHT presented with abdominal pain and mass. In 6 of the 11 patients, varices were detected incidentally on preoperative imaging studies or discovered intraoperatively. Therefore, pre-operative search for varices is required in patients with splenic torsion.

Torsion of Wandering Spleen and its adherence to the right ovary - An unusual cause of recurrent pain abdomen

Wandering spleen is a rare condition in which the spleen is hypermobile due to laxity or lack of its supporting ligaments. It can be located anywhere in the abdomen besides its usual position. The other terms that are used to describe this condition are splenic ptosis, displaced spleen, dislocated spleen and ectopic spleen. Splenic torsion is a dreaded complication and the usual cause of symptoms. There is a high chance of missing the diagnosis as it remains asymptomatic or may be incidentally discovered on radio-imaging done for a different purpose. An acute abdomen is the most common presentation. Here we describe an unusual case presenting with torsion of the wandering spleen that was adherent to the right ovary.

Torsion of Wandering Spleen with Infarction

Wandering spleen is a rare entity that results from the absence or maldevelopment of the ligaments that support the spleen in its normal location. As a result, the spleen is hypermobile and may be predisposed to hilar torsion and subsequent infarction, making it a potentially fatal abdominal emergency. We present a case of a 36-year-old Afghan female who presented with an acute abdomen, and was radiologically and surgically confirmed to have a wandering spleen with torsion and complete infarction. Knowledge of this condition and its radiological findings can play a crucial role in making a correct and timely diagnosis.

Computed Tomography of Cystic Lymphangioma in a Wandering Spleen

A large cystic lymphangioma in a wandering spleen was discovered by chance in a young woman, 2 months after she delivered her first child. The clinical finding was that of a pelvic mass, which at CT was found to be a wandering spleen, containing multiple cystic lesions. The diagnosis of cystic lymphangioma was made at the pathological examination of the specimen after splenectomy. The association of cystic lymphangioma in a wandering spleen has not been reported previously.

Torsion of a Wandering Spleen Presenting as Acute Abdomen

Background

Wandering spleen is a rare condition which if uncorrected, can result in torsion and infarction. Clinical presentation of a wandering spleen can vary from asymptomatic abdominal mass to acute abdominal pain. Radiological investigations play a pivotal role in diagnosis as the clinical diagnosis is usually impossible.

Case Report

We present a case of wandering spleen with torsion and complete infarction that occurred in a 32-year-old multiparous female. The diagnosis was established preoperatively on colour Doppler and CT of the abdomen with subsequent confirmation on surgery.

Conclusions

Wandering spleen is a rare clinical condition which can present as acute abdomen. An increased awareness of this entity together with the timely use of ultrasound and CT of the abdomen can play an important role in preoperative diagnosis and surgical management.

Tale of a wandering spleen: 1800 degree torsion with infarcted spleen and secondary involvement of liver

Wandering spleen is a rare clinical entity characterized by splenic hypermobility resulting from laxity or maldevelopment of the suspensory splenic ligaments. The spleen can "wander" or migrate into various positions within the abdomen or pelvis due to this ligamentous laxity. It is usually detected between 20 and 40 years of age, and is more common in women. The clinical presentation of a wandering spleen is variable, it could present as an asymptomatic, incidentally detected, abdominal or pelvic mass, or as an acute abdomen secondary to splenic torsion. Diagnosis in an emergent setting can be challenging as it is a rare cause of acute abdomen and does not produce any symptoms until splenic torsion has occurred. We present and discuss a case of ectopic, torsed spleen resulting in complete infarction of the spleen and severe hepatic vascular compromise, diagnosed by ultrasound, confirmed by computed tomography and effectively managed by splenectomy.

Surgical Treatment of Patients with Wandering Spleen: Report of Six Cases with a review of the literature

Wandering spleen, which is defined as a spleen without peritoneal attachments, is a rare disease and a delay in the clinical and/or radiological diagnosis may lead to splenic torsion, infarction, and necrosis. Owing to the physiologic importance of the spleen, especially in children, and the risk of postsplenectomy sepsis, early diagnosis and splenopexy are recommended. In the present article, we describe the results of our management of this rare problem on six patients, and we review all available literature from 1895 to 2005. Briefly, our technique includes flap creation from parietal peritoneum and settlement of spleen in the fossa splenica. Free edges of this flap are stitched to the stomach and the left end of transverse colon and the beginning of the descending colon. The body of the stomach was stitched to the abdominal wall to prevent gastric volvulus, while the fundus region was fixed to the diaphragm to support the spleen. Finally, an omental patch was stitched to the intact abdominal wall above the flap. In conclusion, the procedure of splenopexy without using mesh is considered to be a safe and curative modality for wandering spleen without imposing any undue risk of infection or foreign material reaction.

Wandering spleen: a rare cause of abdominal pain

Torsion of a wandering spleen is a rare cause of abdominal pain in children. The most common presentation is acute abdominal pain, although signs and symptoms vary widely. Due to the risk of splenic infarction, rapid and accurate diagnosis is essential. Wandering spleen and splenic torsion can be diagnosed by Doppler ultrasound and CT scan. Treatment options include splenopexy or splenectomy. This case describes a 9-year-old girl with torsion of a wandering spleen, complicated by splenic infarction and managed by splenectomy.

A wandering spleen. Detection by In-111 leukocyte imaging

A wandering spleen is a rare condition characterized by splenic malposition due to congenital maldevelopment or laxity of the supporting ligamentous structures that usually fixate the anatomical position of the spleen. The diagnosis is often difficult to make clinically. In this report, a case is described in which an In-111 oxime labeled leukocyte scan was helpful in making a diagnosis of a wandering spleen.

The value of combined 99mTc-Sn-colloid and 99mTc-RBC scintigraphy in the evaluation of a wandering spleen

Wandering spleen is the term commonly applied to splenic hypermobility that results from laxity or maldevelopment of its suspensory ligaments. It comes to medical attention usually as an abdominal mass, or when the spleen undergoes torsion. Diagnosis on clinical grounds alone is rarely made, and ultrasonography, CT and MRI findings have no specific characteristics for this condition. 99mTc-labeled colloid taken up by the spleen may provide a specific diagnosis. We report a case of wandering spleen, in which the preoperative diagnosis was made on the basis of sequential liver-spleen scintigraphy with 99mTc-Sn-colloid and blood-pool scintigraphy with 99mTc-RBC. This is a rare case, in which hypermobility was assessed by sequential 99mTc-Sn-colloid scintigraphy, and to our knowledge, is the first case in which 99mTc-RBC scintigraphy provided useful information on splenic blood volume and its location.

Wandering accessory spleen

A patient with an excessively mobile accessory spleen detected on ultrasound examination is reported in whom a normally located spleen was also found. Sonographic and colour Doppler imaging criteria were used for making the specific diagnosis. The large accessory spleen has been demonstrated at different sites within the abdomen on subsequent follow-up sonographic examinations. The splanchnic flow pattern obtained from the long vascular pedicle of the accessory spleen indicated normal perfusion. Since the perfusion of the wandering accessory spleen was not compromised by torsion, and the patient refused surgical intervention, a conservative approach was considered to be appropriate.

Recognition of malposition of the liver and spleen: CT, MRI, nuclear scan and fluoroscopic imaging

Thirteen children initially suspected to have an intrathoracic or intraabdominal mass had malposition of the liver and/or spleen discovered by ultrasound. This group consisted of five children with diaphragmatic eventration or hernia and eight with wandering spleen or liver. Careful ultrasonographic examinations were diagnostic in all patients; seven had surgical confirmation. CT, MRI, nuclear scan and fluoroscopic imaging were useful in select instances. The liver and spleen have a characteristic anatomic configuration and sonographic appearance that should enable them to be recognized, and pathological alterations appreciated, even when these organs are ectopic in location or malformed.

Wandering spleen and gastric volvulus

Gastric volvulus and wandering spleen are related to anomalies in the intraperitoneal visceral attachments. When encountered during infancy, they have a congenital origin with acquired predisposing factors. Wandering spleen is a rare clinical entity with a diverse form of presentation. To our knowledge, gastric volvulus associated with wandering spleen has not been reported previously in literature.

Torsion of wandering spleen: the whorled appearance of the splenic pedicle on CT

Congenital deficiency or acquired laxity of the suspensory ligaments of the spleen may result in extreme splenic mobility. This rare condition, which is termed wandering or ectopic spleen predisposes the elongated splenic pedicle to torsion. We present a case of splenic torsion with a new CT finding consisting of a whorled appearance of the splenic pedicle. To our knowledge this finding has not been described before.

Pediatric wandering spleen: case report and review of literature

Wandering spleen is a rare diagnosis, especially in the pediatric population. We reviewed the English literature from 1900 through April 1991 for all cases of wandering spleen in patients from birth through age 10. There are 50 case reports prior to the one presented here. The goals of this article are to summarize the histories, findings, and treatment of the 51 patients, describe diagnostic and treatment modalities, and increase the clinician's suspicion for wandering spleen. This condition is probably underdiagnosed and potentially treatable by splenopexy if suspected and diagnosed early in the course of disease.

Sonographic Evaluation of an Ectopic Spleen Simulating a Pelvic Mass

The presence of a pelvic spleen is an exceedingly rare occurrence. Correct diagnosis, which is essential for appropriate management, can be suggested by sonographic evaluation and confirmed with the use of computed tomography. The case presented here demonstrates the necessity of examination of the entire abdomen by sonography when a pelvic mass of unknown etiology is encountered.

Torsion of a wandering spleen in a one month old, with a confusing ultrasound examination

Torsion of a wandering spleen is an uncommon diagnosis and rare in children. The entity is commonly misdiagnosed. In our case, a one month old infant presented with an abdominal mass. Ultrasound identified a large heterogeneous mass but also revealed what appeared to be normal splenic tissue below the left hemidiaphragm. The ultrasound findings steered us away from the diagnosis of wandering spleen or splenic infarction. Differential diagnosis of the mass included twisted hemorrhagic ovarian cyst, neoplastic mass, or inflammatory abscess. Postoperative histologic analysis demonstrated splenic infarction.

Pediatric wandering spleen--the case for splenopexy: review of 35 reported cases in the literature

Wandering spleen is an uncommon diagnosis and has been rarely described in children. A review of the English literature yielded 35 reported cases in children less than 10 years of age. Eighteen (51%) presented as acute surgical emergencies, only eight of which had the correct diagnosis of pedicle torsion with splenic infarction established preoperatively. Thirteen patients underwent an elective laparotomy, either for chronic symptoms related to their wandering spleen or for an abdominal mass. Of the 13 patients electively managed, nine underwent a splenectomy while five were treated successfully with splenopexy. The remaining four patients were managed conservatively without surgical intervention. In only one third of the patients presenting as acute surgical emergencies was there any history of intermittent abdominal pain or of a previous abdominal mass. No deaths were reported. Males represented 63% of the patients. The occurrence was most common in patients less than 1 year of age, with a 6:1 male predominance in this age category. All acute cases of wandering spleen in which splenic infarction has occurred require splenectomy. However, in patients with chronic symptoms or in whom the diagnosis is made prior to splenic infarction, splenopexy should be the treatment of choice. Past recommendations of splenectomy or conservative nonsurgical management are not indicated. Literature on pediatric wandering spleen is reviewed herein, and a technique for splenopexy using Dexon mesh is described.

Chronic torsion of the wandering spleen

Torsion of a wandering spleen can occasionally produce chronic disabling clinical findings that are mistaken for a variety of digestive disturbances. Since the clinical complaints are misleading, a correct and timely radiographic analysis can prevent an extensive but unnecessary pursuit of other more common conditions. Images of an ectopic, enlarged, disoriented spleen with a devitalized parenchyma and adherent pseudocapsule can quickly establish the diagnosis of chronic splenic torsion.

Imaging the effects of an ectopic spleen on the urinary tract

A 75-year-old woman with chronic lymphocytic leukemia who presented clinically with urinary frequency was found on physical examination to have a pelvic mass. Ultrasound and computed tomography showed it to be due to a large ectopic spleen lying in the pelvis behind the bladder and compressing it anteriorly. The spleen became smaller and the symptoms regressed with chemotherapy. We review the features of an ectopic spleen as seen on diagnostic imaging studies.

Sonography of the Spleen

With the advent of real-time sonography of the upper abdomen, the spleen is no longer an inaccessible organ. Real-time imaging is preferable to other conventional diagnostic methods because of its simplicity and accuracy in evaluation of the spleen and the determination of its relationship to other organs. This review of the literature details the diagnosis of splenic pathology by sonography and includes a discussion of the significance of these findings.

Torsion of a wandering spleen in an infant. Report of a case and a brief review of the literature

A case of torsion of the wandering spleen in an infant is presented. The value and limitations of various imaging modalities in making a correct preoperative diagnosis are discussed and a brief review of the literature is given.

Clinical studies with spleen-specific radiolabeled agents

While 99mTc sulfur colloid imaging, because of its availability and convenience, remains the initial procedure of choice for spleen imaging, selective spleen scanning with damaged 99mTc-labeled RBCs can provide additional information in some cases. These cases include overlapping left hepatic lobe and suspected splenic pathology but with poor radiocolloid uptake that precludes visualization. Other indications are detection of residual splenic tissue after splenectomy, suspected asplenia, polysplenia, and situs ambiguus. The selective 99mTc-denatured RBC scan is most useful to confirm or exclude defects seen on the radiocolloid study and to detect small amounts of splenic tissue.

The spleen: development and functional evaluation

Despite the fact that the spleen has multiple functions, only one has been widely used for evaluation of the organ by imaging techniques (phagocytosis of 99mTc sulfur colloid). The usual splenic uptake of this radiocolloid can by used to determine the size, location, and integrity of the organ. A major use of splenic radiocolloid imaging has been in the study of congenital defects. Thus, eventration of the diaphragm, accessory spleens, splenogonadal fusion, the asplenia and polysplenia syndromes, and the wandering spleen are amenable to study by means of intravenously administered radiocolloid. Interference with the splenic uptake of radiocolloid can be either focal or generalized (as in functional asplenia). Imaging of the spleen has a major role in evaluating suspected trauma of the organ and in following its clinical course. The return of splenic function after splenectomy (splenosis or accessory spleens) can be documented by radionuclide imaging, and likely by hematologic techniques when the volume of tissue is sufficiently large. The detection of intrasplenic lesions is important in tumor staging and as an alerting sign to an ongoing process.

Torsion of a wandering spleen

We present an unusual case of torsion of a wandering spleen in a 14 year old boy. Wandering spleen is an entity which has rarely been reported in infants and children. Although patients may be asymptomatic, some may present as an acute surgical emergency if trauma or torsion of the vascular pedicle occurs, as in our case. The treatment of this condition is splenectomy.

Abdominal pseudotumor caused by gastric displacement of the spleen: sonographic demonstration

An infant with a factitious abdominal mass due to splenic displacement by the distended stomach is described. Two other cases of this phenomenon have been previously reported, both in infants and both diagnosed by radionuclide scans and plain radiographs. In our patient, diagnosis was made with ultrasound without the need for further studies.

Splenic torsion presenting as a twisted hemorrhagic ovarian cyst

Torsion of a wandering spleen is rare, usually presenting as an acute abdomen and commonly misdiagnosed. In our case, a 14-year-old girl was diagnosed preoperatively as having a twisted hemorrhagic ovarian cyst. On laparotomy, an infarcted spleen that was twisted on its pedicle was found in the lower abdomen. The patient recovered uneventfully. The clinical spectrum of wandering spleen is discussed briefly.

Acute gastric hemorrhage secondary to wandering spleen

A patient presenting with acute life-threatening upper gastrointestinal hemorrhage caused by a wandering spleen is reported. Emergency laparotomy revealed profuse gastric bleeding, large engorged varicose veins in the gastric wall, and a normal liver parenchyma. Gastroscopy after arrest of the hemorrhage showed varicose veins in the fundus without esophageal varices. Angiography revealed an ectopic spleen, occlusion of the splenic vein, and large venous collaterals in the gastric fundus. Elective splenectomy was performed. Wandering spleen as a cause of left-sided portal hypertension, also referred to as segmental splenic hypertension, is discussed.

The wandering spleen

The article presents two cases of wandering spleen in the pediatric age group. Both patients were admitted for abdominal pain. In one, the onset was sudden and, on physical examination, a mass was felt in the left hypochondrium. In the other, it was the second episode and a firm mid-abdominal mass was found. The wandering spleen is a specific clinical syndrome which should be taken into account when an abdominal tumor is found. Ultrasonography and isotopic scan are very useful diagnostic tools The wandering spleen is caused by the absence of the splenorenal ligament which allows increased mobility of the splenic hilum. Both children underwent a splenectomy and made an uneventful recovery.