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| CASE REPORT |
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| Year : 2018 | Volume
: 23
| Issue : 1 | Page : 40-42 |
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Wandering spleen with torsion presenting as acute abdomen
Puneet Mittal, Ranjana Gupta
Department of Radiodiagnosis, Maharishi Markandeshwer Institute of Medical Sciences and Research, Mullana, Ambala, Haryana, India
| Date of Web Publication | 3-Apr-2018 |
Correspondence Address:
Dr. Puneet Mittal
448, Opp. Singla Memorial Hospital, Prem Basti, Sangrur - 148 001, Punjab
India
 Source of Support: None, Conflict of Interest: None  | Check |
DOI: 10.4103/jmgims.jmgims_26_16
Wandering spleen is a rare condition resulting from laxity of the suspensory ligaments of the spleen which predisposes it to torsion. We present a 24-year-old female who presented with acute abdominal pain due to torsion of the wandering spleen.
Keywords: Computed tomography scan, ultrasound scan, wandering spleen
How to cite this article:
Mittal P, Gupta R. Wandering spleen with torsion presenting as acute abdomen. J Mahatma Gandhi Inst Med Sci 2018;23:40-2 |
| Introduction | |  |
Wandering spleen is a very rare condition resulting from laxity of splenic suspensory ligaments which can be congenital or acquired. This increased mobility is responsible for the abnormal position of the spleen in the abdomen which can be located in the abdomen lower than its normal position or it can be located in the pelvis. In adults, it is common in females in the reproductive age group when acquired laxity of ligaments is thought to play a role which could be due hormonal changes in this age group. This increased mobility also predisposes it to acute, intermittent, or chronic torsion. Acute torsion is a surgical emergency which can be potentially life-threatening. Splenic torsion is, therefore, important to recognize whenever spleen is identified in an abnormal location. We present imaging findings in a young female who presented with acute abdominal pain secondary to torsion of wandering spleen.
| Case Report | | |
A 24-year-old multiparous female patient (with two alive children) presented with acute abdominal pain in hypogastric and left the lumbar region for the past 1 day. There was a similar history of low-grade intermittent pain in the left lumbar region for 2–3 years. There was no history of trauma, vomiting, bowel, or urinary complaints. On general examination, she was afebrile with vague lump felt in the left lumbar region. Laboratory investigations were within the normal limits except for mild leukocytosis (total leukocyte count-13000/mm3) Ultrasound [Figure 1] revealed that spleen was located anteroinferior to the left kidney. There was whirling of splenic vessels at splenic hilum suggesting torsion with also mild twisting of the tail of the pancreas. Splenic echotexture was heterogeneously hypoechoic with no flow on color Doppler. The minimal fluid was seen at splenic hilum due to vascular engorgement and peritoneal irritation. On noncontrast computed tomography (NCCT) [Figure 2], wandering spleen was seen antero-inferior to the left kidney with positive whirl sign with the twisting of vessels at splenic hilum with suspicion of mild twisting of the distal tail of the pancreas. Patient's serum amylase and lipase levels were normal, thus ruling out acute pancreatitis. The patient underwent laparotomy with a midline incision. Spleen was found in an abnormal location in the lower abdomen and in was necrotic with the twisting of its pedicle [Figure 3]. Splenectomy was done due to nonviability of the splenic tissue. The patient made uneventful postoperative recovery. | Figure 1: Ultrasound images show abnormal position of spleen with whirled appearance of vessels at splenic hilum (white arrows). Note heterogeneously hypoechoic echotexture of spleen
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 | Figure 2: Axial noncontrast computed tomography images twisting of pancreatic tail (a), positive whirl sign (b) and abnormal position of spleen anteroinferior to left kidney(c)
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| Discussion | | |
The normal position of the spleen in the abdomen is in the left upper quadrant and is fixed by various ligaments such as lienorenal, gastrosplenic, and phrenicocolic ligaments to the adjoining organs.[1] Increased mobility of spleen results from weakening or laxity of these ligaments which is usually developmental but can be acquired secondary to trauma or connective tissue disorders.[2] In either case, there is a long pedicle containing splenic vessels and sometimes pancreatic tail predisposing to torsion. Since pancreas also develops in dorsal mesogatrium, if the fusion of dorsal mesogastrium to the posterior parietal peritoneum is incomplete, then some portion of the pancreatic tail may be intraperitoneal and be involved in splenic torsion.[3]
Wandering spleen with torsion is a very rare condition accounting for <1% of all splenectomies. It is much more common in females, usually young (20–40 years).[2],[3] Increased prevalence in females of childbearing age could be due to hormonal influences or due to ligamentous laxity secondary to pregnancy. Most of the cases in females are seen in multiparous females in which multiple pregnancies are thought to contribute to ligamentous laxity. The fact that most of the cases do not present in the first two decades supports the acquired rather than congenital laxity of ligaments as the cause of this condition.[4] In the 1st year of life, there is slight male predominance and mode of presentation is as abdominal mass due to the abnormal position of spleen rather than torsion. Only isolated cases are reported in the early years of life up to the age of 10 years.[3],[4]
Patients may be asymptomatic or present with intermittent or chronic abdominal pain. Often, diagnosis is delayed until they present with sudden onset of severe pain secondary to acute torsion. In acute torsion, the whorled appearance of splenic vessels “whirl sign” is specific for torsion.[5] There may be associated torsion of the tail of the pancreas. However, it may or may not be associated with features of acute pancreatitis.[2]
Splenic torsion may be associated with splenic infarction. On ultrasound, there will be no vascularity within the splenic parenchyma, and it will show lower than normal echogenicity as seen in our case. Similarly, on NCCT, the infracted spleen may show lower attenuation than normal. On postcontrast images, it may not show any enhancement or only rim enhancement may be seen.[2]
Clinical diagnosis of wandering spleen is difficult, and imaging has an important role in its diagnosis. Imaging also helps to assess the viability of splenic parenchyma which helps to guide appropriate surgical management. If wandering spleen is diagnosed incidentally in asymptomatic individuals, splenopexy is the treatment of choice to prevent any future episodes of torsion. In cases presenting with acute torsion, management depends on the status of splenic parenchyma. It cases of splenic infarction and necrosis, splenectomy is the treatment of choice, as was done in our case.[5],[6]
| Conclusion | | |
Wandering spleen is a rare condition characterized by the abnormal position of the spleen in the abdomen due to ligamentous laxity and is more common in women in reproductive age group. It may be detected incidentally when it should be treated with splenopexy to prevent torsion. When in presents with acute torsion, management depends on the viability of splenic parenchyma with splenectomy required with splenic infarction and necrosis are present. This diagnosis should always be considered when a patient presents with acute abdominal pain and spleen is not seen in its usual location in right upper quadrant.
Declaration of patient consent
The authors certify that they have obtained all appropriate patient consent forms. In the form the patient(s) has/have given his/her/their consent for his/her/their images and other clinical information to be reported in the journal. The patients understand that their names and initials will not be published and due efforts will be made to conceal their identity, but anonymity cannot be guaranteed.
Financial support and sponsorship
Nil.
Conflicts of interest
There are no conflicts of interest.
| References | | |
| 1. | Safioleas MC, Stamatakos MC, Diab AI, Safioleas PM. Wandering spleen with torsion of the pedicle. Saudi Med J 2007;28:135-6.  [ PUBMED] |
| 2. | Ben Ely A, Zissin R, Copel L, Vasserman M, Hertz M, Gottlieb P, et al. The wandering spleen: CT findings and possible pitfalls in diagnosis. Clin Radiol 2006;61:954-8. |
| 3. | Lam Y, Yuen KK, Chong LC. Acute torsion of a wandering spleen. Hong Kong Med J 2012;18:160-2. |
| 4. | Arleo EK, Kovanlikaya A, Mennitt K, Acharya S, Brill PW. Multimodality imaging of a neonatal wandering spleen. Clin Imaging 2010;34:302-5. |
| 5. | Jiang M, Chen P, Ruan X, Ye X, Huang Q. Acute torsion of wandering spleen in a 17-year-old girl. Int J Clin Exp Med 2015;8:11621-3. |
| 6. | Aswani Y, Anandpara KM, Hira P. Wandering spleen with torsion causing pancreatic volvulus and associated intrathoracic gastric volvulus. An unusual triad and cause of acute abdominal pain. JOP 2015;16:78-80. |
[Figure 1], [Figure 2], [Figure 3]
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