Transcript wandering spleen * course of events

WANDERING SPLEEN – COURSE OF EVENTS
ABSTRACT ID: 1154
OBJECTIVES
• To determine the role of imaging studies in
diagnosing wandering spleen, a rare condition
with common clinical presentation like
abdominal pain.
• To identify the location, vascular status for
appropriate management.
• The spleen develops from the mesoderm in the
dorsal mesogastrium. It lies in the left
hypochondrium behind the stomach, and is
about 12 × 7 cm
• The spleen is fixed in position by the lieno-renal
and gastro-splenic ligaments; the phrenico-colic
ligament provides additional support.
• Wandering spleen also called ectopic spleen, is a
rare clinical occurrence with fewer than 500
cases reported in literature
• Wandering spleen is defined as a 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 ligament.
• 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 the
size in the spleen.
• Clinical presentation is variable. Patients can be
asymptomatic or may have chronic vague
abdominal pain.
• They may present as acute abdomen when there
is infarction due to torsion of pedicle.
Case history
• A 19 yr old female presented with chronic lower
abdominal pain. Her routine blood
investigations were inconclusive.
• She was referred for Ultrasonography.
• Ultrasound of abdomen showed absence of
spleen in left hypochondrium. A well-defined,
homogenous hypoechoic mass measuring 17x 8
cm seen in the pelvis on left side extending to
midline.
o The mass is seen to compress the bladder and
pushing the uterus.
o Hilar vessels were made out ,and showed mild
color flow on doppler evaluation. However the
spleen looked congestive.
o Other abdominal organs showed no significant
abnormality.
o A diagnosis of wandering spleen with possible
partial torsion of vascular pedicle was given.
USG images showing spleen in pelvis, ectopic location.
Spleen seen in pelvis adjacent to uterus. Doppler USG
showing mild color flow in the pedicle.
CECT ABDOMEN
• Four days later the patient presented with acute
abdominal pain.
• Computed tomography of abdomen was done which
showed enlarged spleen in pelvis with a long
vascular pedicle attached to pancreatic tail.
• On contrast study the spleen showed no
enhancement. The vascular pedicle was seen twisted
just above the level of pelvis causing vascular
compromise and infarction of spleen.
• The pancreatic tail was normally enhancing.
• There were no other areas of infarction.
A
B
CECT Axial images. A. Spleen not seen in left hypochondrium.
B. Spleen seen in ectopic location ,pelvis.
a
b
CECT: a. Axial and b. Coronal reformatted images showing
non-enhancing pedicle and spleen.
a
b
a. sagittal, b. coronal reformatted images showing
enhancing vascular pedicle upto the level of twisting.
TORSION OF WANDERING SPLEEN
CURVED MPR
showing the
vascular pedicle
twisted causing
infarction of
spleen.
TORSION OF PEDICLE
Video clip of sequential
CECT images showing
twisted oedicle.
• Diagnosis of wandering spleen with torsion was
given.
• Patient underwent laporotomy.
• Spleen along with a part of vascular pedicle were
removed.
Per operative images showing pedicle, spleen
CONCLUSION
 Though rare, wandering spleen should be
considered as a part of differential diagnosis in
patients presenting with lower abdominal pain,
palpable mass etc., and when not seen in usual
position.
 Only treatment for wandering spleen is surgery,
which will be either splenopexy [salvaging] or
splenectomy.
 Imaging by ultrasound, computed tomography
confirms the diagnosis. More importantly the
vascular supply, and thus helps in appropriate
management avoiding the complications like
gangrene, pancreatic tail infarction etc.,
REFERENCES
• Sharma and Salerno Journal of Medical Case
Reports 2014, 8:133
• Alawi MH, Khalifa A, Bana H. Wandering spleen: a
challenging diagnosis. Pak J Med Sci
2005;21(4):482–4.
• Taori K, Ghonge N, Prakash A. Wandering spleen
with torsion of vascular pedicle. Abdom Imaging
2004; 29:479–481.
• Danaci M, Belet U, Yalin T. Power Doppler
sonographic diagnosis of torsion in a wandering
spleen. J Clin Ultrasound 2001; 28:246–248