Splenosis presenting as occult gastrointestinal bleeding

Refractory Immune Thrombocytopenic Purpura with Abdominal Splenosis: A Complex Case

Immune thrombocytopenia (ITP) is an acquired thrombocytopenia resulting from immune-mediated platelet destruction via antiplatelet antibodies and T cells. Medical management of ITP includes corticosteroids and multiple other adjunct therapies, with splenectomy generally being reserved for severe, refractory cases. In this clinical case report, we describe the evaluation of a 35-year-old male with a history of prior traumatic splenic injury who presented to the emergency department endorsing easy bruising and a petechial rash, ultimately found to have severe thrombocytopenia. The patient was diagnosed with primary ITP that proved to be refractory to a number of first- and second-line medical therapies. His course was complicated by the presence of abdominal splenosis discovered at the time of planned splenectomy and intra-abdominal hemorrhage requiring splenic artery embolization thereafter. To our knowledge, this is one of few published cases of ITP complicated by abdominal splenosis, highlighting the need to consider splenosis and the presence of accessory splenic tissue in cases of refractory ITP.

Acquired Gastric Dieulafoy-Like Lesion due to Aberrant Blood Supply Diverted From the Left Phrenic Artery to an Enlarged Splenule

Dieulafoy lesion is an aberrant submucosal vessel that can erode into the overlying tissue leading to hemorrhage. It is a rare but important cause of gastrointestinal bleeding. We present a case of a patient who developed an acquired Dieulafoy lesion 39 years after splenectomy. Abdominal computed tomography showed an aberrant vessel from a branch of the left phrenic artery, coursing through the gastric fundus to supply a splenule. Angiography with embolization of the aberrant vessel resulted in no further bleeding.

Calcification in Thoracic Splenosis

Splenosis is a rare condition described as the implantation of ectopic splenic tissue, usually after a splenic rupture. Thoracic splenosis refers to acquired ectopic splenic tissue found within the thoracic cavity, often caused by thoracoabdominal trauma or surgery. Most cases are asymptomatic and many years may elapse before they are incidentally discovered on chest radiography or thoracic computed tomography. Splenosis is often misinterpreted as a malignancy on initial imaging. We wish to highlight a rare case of thoracic splenosis presenting with calcified and non-calcified nodules. Only two other cases of calcification have been reported in intrathoracic splenosis, neither of which provided CT images of this finding.

Abdominal and pelvic splenosis: atypical findings, pitfalls, and mimics

Splenosis is an acquired form of ectopic splenic tissue that typically arises after trauma or splenectomy. It is often an incidental image finding in an otherwise asymptomatic patient, but the spectrum of symptoms varies based on the site of implantation. Radiologists should be familiar with the imaging features of splenosis to avoid mistaking it for malignancy. Splenosis has identical imaging features to that of the native spleen on US, CT, MRI, and nuclear medicine examinations. Therefore, when the radiologic findings support the diagnosis of splenosis, the patient can be spared invasive procedures for tissue sampling.

Extensive intrathoracic and intraperitoneal splenosis mimicking mesothelioma: a case report

Background

Splenosis is the heterotopic autotransplantation of splenic tissue after severe splenic trauma and/or splenectomy. The epidemiology is elusive, but splenosis is frequently misdiagnosed as malignant tumors of gastrointestinal, gynecological, or hematological origin before the correct diagnosis is ultimately found. We herein report a rare case of combined, extensive intraabdominal and intrathoracic splenosis initially presenting as pleural mesothelioma.

Case presentation

A 63-year-old Caucasian male presented with dyspnea and recurring thoracic pain. Initial X-ray and computed tomography scans showed disseminated intrathoracic and intraabdominal lesions. Consequently, thoracoabdominal mesothelioma or a polytopically metastasized cancer of unknown origin was suspected. A thorough examination of the patient’s medical history and contrast-enhanced ultrasound by a skilled examiner revealed the diagnosis of extensive abdominal and thoracic splenosis as a consequence of an abdominal gunshot wound with a ruptured diaphragm several decades earlier. Timely diagnosis by noninvasive measures prevented the patient from potential complications of harmful diagnostic procedures, including nuclear imaging and biopsies. The patient is currently treated for hepatitis C and chronic obstructive lung disease, whereas no specific treatment for splenosis is required.

Conclusions

We present a case of rare intrathoracic and intraperitoneal splenosis mimicking mesothelioma. Contrast-enhanced ultrasound and thorough patient history were used for diagnosis and prevented this patient from having to undergo potentially harmful diagnostics. Splenosis can occur after splenic trauma and, consequently, needs to be considered as a rare differential diagnosis to malignant tumors of various origins when a matching patient history is obtained.

Case report: A follow up of a major pelvic splenosis

The authors present a case of a young female with extensive pelvic splenosis, which was complicated by torsion of one of the splenosis nodules operated by laparoscopy. She has been followed during several years. The diagnosis was made on the basis of the history, imaging (ultrasound, CT scan, MRI, and Technetium 99m-labeled embrittled red blood cell scans), and blood workup. The diagnosis of splenosis can be made via complications such as torsion, infarction, hemorrhage, or most often incidentally. The treatment without symptoms is abstention.

Pelvic splenosis mimicking a suspicious adnexal mass

A 58-year-old asymptomatic woman was referred to our gynecologic oncology unit for the management of a left adnexal mass found during a routine gynecologic examination. Her personal history included an emergency splenectomy at the age of 4 years old, following traumatic splenic laceration after a car accident. The patient's work-up (including transvaginal ultrasound and MRI) confirmed a pelvic solid mass, which was reported as suspicious for malignancy and classified as Ovarian-Adnexal Reporting & Data System-MRI 5. An exploratory laparoscopy was performed, showing a reddish blue lesion located at the left broad ligament. Histologic analysis showed the presence of splenic tissue and normal adnexa. The postoperative follow-up was uneventful.Pelvic splenosis is a challenging diagnosis rarely made preoperatively due to concern for malignancy. In the presence of a pelvic mass, the collection of a detailed patient's history, including information about previous splenic rupture, might raise suspicion for pelvic splenosis.

Abdominal splenosis and its differential diagnoses: What the radiologist needs to know

Splenosis is a benign acquired condition characterized by the presence of heterotopic viable splenic tissue in other organs or within cavities such as peritoneum, retroperitoneum, or thorax after splenic trauma or surgery. Abdominal splenosis is often an incidental finding and computed tomography and magnetic resonance usually allow a confident diagnosis. The typical enhancement that parallels the spleen is a useful hallmark of splenosis. Splenic implants lack contrast uptake in the hepatobiliary phase and show high signal at high b-values on diffusion-weighted images. In some cases splenosis may mimic malignant and benign conditions in the peritoneum as well as in hollow and parenchymal abdominal organs and further investigations - including scintigraphy with Tc99m-labelled heat-denatured red blood cells or biopsy - are sometimes required in challenging cases. This pictorial essay reviews the imaging presentation and potential differential diagnosis of splenosis according to the site of implantation. A prompt and accurate radiological diagnosis of splenosis can avoid unnecessary biopsy or surgery.

Splenosis of the Mesoappendix with Acute Appendicitis: A Case Report

BACKGROUND Splenosis is a benign condition involving the auto-transplantation of splenic tissue at various locations, resulting from splenic injury or splenectomy. CASE REPORT A 40-year-old male, with a history of remote exploratory laparotomy with splenectomy secondary to blunt abdominal trauma, presented with symptoms consistent with acute appendicitis, which was subsequently confirmed by computed tomography scan of the abdomen that further demonstrated the presence of multiple abdominal nodules, one of which was adjacent to the appendix. A laparoscopic appendectomy was then performed along with resection of the nodule located in the mesoappendix, which was confirmed to be a splenic tissue based on histopathological examination. CONCLUSIONS Abdominal splenosis is not an uncommon condition in patients with a history of splenic injury. However, the involvement of the mesoappendix, which may or may not contribute to acute inflammation of the appendix, is very rare.

Outcome of Laparoscopic Splenectomy for Malignant Hematologic Diseases

Aim

The role of laparoscopic splenectomy in the treatment of hematological diseases is still controversial. The aim of this study was to assess whether the benign or malignant nature of hematological diseases may influence the outcome of laparoscopic splenectomy.

Patients and methods

Between August 1997 and March 2002, 63 unselected patients with hematologic diseases underwent a laparoscopic splenectomy. Patients were divided into two groups according to the benign (Group A, 38 patients) or malignant (Group B, 25 patients) nature of the hematological diseases.

Results

Patients in group B were significantly (a) older, (b) had larger spleens that more frequently needed accessory incisions for specimen retrieval, (c) had greater transfusion requirements, and (d) were fed later than patients in group A. There were no statistically significant differences among the two groups in terms of (a) body-mass index, (b) operative time, (c) conversion rate, (d) blood loss, (e) pain medication requirements, and (f) hospital stay. Two postoperative deaths occurred among patients in group B, but none of them was related to surgery.

Conclusions

The results of the study showed that: a) the nature of the disease does not influence the outcome of laparoscopic splenectomy, b) the size of the spleen might increase the risk of conversion, but it is no longer a contraindication to laparoscopic splenectomy, and c) laparoscopic splenectomy can be effectively performed in the treatment of malignant hematologic diseases.

Splenosis involving the gastric fundus, a rare cause of massive upper gastrointestinal bleeding: a case report and review of the literature

Splenosis, the autotransplantation of splenic tissue following splenic trauma, is uncommonly clinically significant. Splenosis is typically diagnosed incidentally on imaging or at laparotomy and has been mistakenly attributed to various malignancies and pathological conditions. On the rare occasion when splenosis plays a causative role in a pathological condition, a diagnostic challenge may ensue that can lead to a delay in both diagnosis and treatment. The following case report describes a patient presenting with a massive upper gastrointestinal bleed resulting from arterial enlargement within the gastric fundus secondary to perigastric splenosis. The cause of the bleeding was initially elusive and this case highlights the importance of a thorough clinical history when faced with a diagnostic challenge. Treatment options, including the successful use of transarterial embolization in this case, are also presented.

A Lower Gastrointestinal Bleeding Due to a Post-Traumatic Splenosis: "Wait and See" Represents a Feasible Attitude: A Case Report

Splenosis represents a benign condition due to an ectopic localization of splenic tissue caused by pathologic or traumatic spleen rupture. Generally, it is asymptomatic and incidentally diagnosed during imaging performed for other reasons. Occult gastrointestinal bleeding due to an extraperitoneal localization is a rare occurrence. Differential diagnosis may be very hard and includes benign and malignant neoplasms.We describe the case of a 68-year-old Caucasian man that was admitted for an increasing lower gastrointestinal bleeding associated to a vague abdominal pain.He was assessed by means of laboratory tests, as well as by endoscopic and radiological examinations, and successfully treated with an exclusive medical approach.The patient was discharged on the ninth day and currently he is doing well.This case shows that wait and see could prove a feasible attitude for the management of clinically stable patients.

Splenosis: A Rare Etiology for Bowel Obstruction-A Case Report and Review of the Literature

Splenosis is a historically uncommon etiology for bowel obstruction. Autotransplanted splenic tissues following surgery or trauma of the spleen are known to occur in multiple locations of the abdominal cavity and pelvis. The small bowel mesentery is a blood vessel-rich environment for growth of splenic fragments. We present a case of a 36-year-old male patient who sustained a gunshot wound to his left abdomen requiring a splenectomy and bowel resection fifteen years prior to his presentation with small bowel obstruction requiring exploration, adhesiolysis, and resection of the mesenteric splenic deposit. Our aim in this report is to provide awareness of splenosis as an etiology for bowel obstruction, especially with increased incidence and survival following abdominal traumas requiring splenectomies. We also stress on the importance of history and physical examination to include splenosis on the list of differential diagnoses for bowel obstruction.

Spontaneous hemorrhage from splenic tissue 13 years after total splenectomy: report of a case

A 33-year-old man suffered sudden abdominal distension without traumatic episodes. He had undergone total splenectomy for hereditary spherocytosis 13 years ago. He was in shock, and his hemoglobin level was 10.5 g/dl. Contrast enhanced computed tomography revealed a giant mass in the left upper abdomen and extravasation of the contrast material into the mass. Excision of the mass was performed, and microscopic examination showed a giant hematoma surrounded by normal splenic tissue. We speculated that an accessory spleen or splenosis had enlarged for the 13 years and ruptured. The patient remained asymptomatic 4 months after the surgery. Spontaneous hemorrhage from accessory spleens or splenosis is extremely rare, and relevant case reports suggest that surgical resection of bleeding sites yields favorable prognosis although preoperative qualitative diagnosis seems to be difficult.

Splenosis: a rare cause of gastrointestinal bleeding successfully treated with transarterial embolization

Splenosis, the ectopic implantation of splenic tissue, most commonly occurs in the peritoneal cavity following traumatic splenic injury with subsequent splenectomy. This entity is asymptomatic in a vast majority of patients. Occult gastrointestinal (GI) bleeding is a relatively rare presentation of splenosis. Previous cases of splenosis resulting in refractory GI bleeding have been treated with surgical excision of the ectopic splenic implant. We report a case of splenosis presenting as occult GI bleeding that was eventually treated with transarterial embolization. This presents an alternative minimally invasive approach to treating a patient with refractory GI bleeding secondary to splenosis.

Selective Spleen Scintigraphy in the Evaluation of Accessory Spleen/Splenosis in Splenectomized/Nonsplenectomized Patients and the Contribution of SPECT Imaging

OBJECTIVE

We aimed to evaluate the results of selective spleen scintigraphy (SSS) and contribution of SPECT imaging to planar imaging in splenectomized and nonsplenectomized patients.

METHODS

We retrospectively examined 112 SSSs of 96 patients. The patients were divided into two groups as splenectomized group (SP) and non-splenectomized group (NSP). The findings were evaluated by comparing the results of surgery,computerized tomography (CT), ultrasonography (USG) and magnetic resonance imaging (MRI). In addition, whether or not differences existed between the results of SPECT and planar imaging was determined.

RESULTS

Of 66 scintigraphies performed in the NSP group, 3 (5%) had positive, 3 (5%) had suspicious and 60 (90%) had negative results. In the NSP group, 28 patients underwent surgery and 12 accessory spleens were removed. Only 3 of these tissues were detected by scintigraphy. Of 46 patients in the SP group, 26 (57%) had positive findings whereas 20 (43%) had negative scintigraphies. Twelve accessory spleens/splenosis were removed surgically in 10 patients with a positive SSS in the SP group. There were no false positive results in both groups of patients who underwent surgery. There was no significant difference between the results of SSS, USG and CT. Of 39 patients to whom SPECT were performed, 10 had positive results both with planar and SPECT imaging. On the other hand, 26 patients, 3 of whom had suspected findings in SPECT images, demonstrated negative results when evaluated with both imaging methods. Remaining 3 were considered suspicious by only SPECT images for the hilar area.

CONCLUSION

SSS has high specificity in the detection of accessory spleens/splenosis. The sensitivity of SSS is low in the NSP group,but higher in the SP group. There is no contribution of SPECT imaging to planar imaging.

CT of splenosis: patterns and pitfalls

OBJECTIVE

After traumatic splenic injury or splenectomy, small isolated spleens may develop. These implants are not limited to the left upper quadrant, and splenosis in other locations can mimic other pathologic entities. This pictorial essay presents the range of appearances of intraabdominal and pelvic splenosis.

CONCLUSION

Radiologists can suggest or establish the correct diagnosis of splenosis in the appropriate clinical setting, particularly in less typical cases, to avert unnecessary tissue sampling.

Intramural colonic splenosis: a rare case of lower gastrointestinal bleeding

BACKGROUND

A 41-year-old man had left upper quadrant abdominal pain, constipation, and melena. About 6 years previously, he received a single gunshot wound to the abdomen, which required partial gastrectomy and small bowel resection. He subsequently developed bleeding gastric varices for which he underwent a splenectomy 2 years before the current admission.

DISCUSSION

A CT scan identified a 6.5 × 2.5 cm left upper quadrant mass. Upper endoscopy was unremarkable, but on colonoscopy, a 3-cm polypoid mass partially obstructed the descending colon. A left hemicolectomy was performed with a primary colonic anastomosis and incidental appendectomy. The mass involved the muscularis of the colon and caused ulceration of the mucosa was ectopic hyperplasic splenic tissue, indicating intramural colonic splenosis. We hypothesize that after the patient's splenectomy, a colonic focus of heterotrophic spleen became hyperplastic and led to a clinically apparent lesion.

Intraperitoneal splenosis: a simple diagnosis if you remember to think of it

A 72-year old man presented with clinical signs of small bowel obstruction. The medical history revealed an asymptomatic retrogastric tumor 5 cm in diameter with impression of the gastric fundus that was found 10 years ago and showed no progression. This diagnosis was made endoscopically, by endosonography and abdominal computed tomography. Finally, as the small bowel obstruction occurred, an explorative laparotomy was performed to clarify the ambiguous abdominal scenario. The intraoperative situs showed multiple red nodules with diameters of up to 1 cm based on the serosa of the small bowel. The histopathological assessments of the peritoneal nodules as well as of the resected retrogastric tumor revealed the diagnosis of splenosis. Retrospectively, the patient reported a road accident with splenic rupture and splenectomy more than 30 years ago. He had simply forgotten this fact and thus had not mentioned it to the examining doctors. The decisive hint for the diagnosis of splenosis results from the thorough inquiry of the medical history, revealing experienced splenectomy. Splenosis should be considered as a crucial differential diagnosis of unexplained masses or occult bleeding in individuals who underwent splenectomy to avoid unnecessary diagnostic or therapeutic procedures.

Intra-Abdominal Splenosis Following Laparoscopic Splenectomy Causing Recurrence in a Child with Chronic Immune Thrombocytopenic Purpura

In this paper, we present the case of a 12-year-old boy with refractory, symptomatic immune thrombocytopenic purpura (ITP) who underwent a laparoscopic splenectomy (LS). During morcellation of the spleen the retrieval bag ruptured. Thirteen (13) months postoperatively, the patient developed further symptoms and was found to be thrombocytopenic. Tc-99m heat-damaged red blood cell scintigraphy showed an accumulation of heat-damaged red cells in the upper left quadrant, raising the possibility of missed accessory spleen. Laparoscopic exploration revealed widespread intra-abdominal splenosis, and a therapeutic omentectomy was carried out. Fourteen (14) months post-surgery, platelet counts improved and the patient remains well. Following an elective splenectomy, a relapse in ITP may be the result of missed accessory spleen or splenosis; in others, it may the result of ongoing platelet consumption in non-splenic, reticulo-endothelial tissue. During LS, consideration must therefore be given to the risk of not only leaving additional splenic tissue behind, but also to the possibility of accidental autotransplantation, such as that from laparoscopic bag rupture. The risk of rupture can be minimized by using blunt instruments and stronger bag materials. If a rupture does occur, immediate suction and a thorough search for splenic fragments must be undertaken. Further development is needed into new techniques for organ retrieval and stronger bag materials.

Infarcted splenule--a case report

A 38-year-old woman presented with abdominal pain and left shoulder pain. A computed tomography scan was obtained, which demonstrated a rounded soft tissue density with surrounding stranding. It was interpreted as an infarcted splenule. Due to the increasing severity of the patient's symptoms, a laparoscopic exploration was performed. Pathology demonstrated an infarcted splenule. As infarcted splenules are rare, an understanding of its pathogenesis and familiarity with the corresponding imaging findings may be helpful for its diagnosis in the patient with the appropriate clinical scenario. It is important to recognize this entity as a cause of abdominal pain that can be managed nonsurgically.

Single-Photon Emission Computed Tomography/Computed Tomography in Abdominal Diseases

Single-photon emission computed tomography (SPECT) studies of the abdominal region are established in conventional nuclear medicine because of their easy and large availability, even in the most peripheral hospitals. It is well known that SPECT imaging demonstrates function, rather than anatomy. It is useful in the diagnosis of various disorders because of its ability to detect changes caused by disease before identifiable anatomic correlates and clinical manifestations exist. However, SPECT data frequently need anatomic landmarks to precisely depict the site of a focus of abnormal tracer uptake and the structures containing normal activity; the fusion with morphological studies can furnish an anatomical map to scintigraphic findings. In the past, software-based fusion of independently performed SPECT and CT or magnetic resonance images have been demonstrated to be time consuming and not useful for routine clinical employment. The recent development of dual-modality integrated imaging systems, which provide SPECT and CT images in the same scanning session, with the acquired images co-registered by means of the hardware, has created a new scenario. The first data have been mainly reported in oncology patients and indicate that SPECT/CT is very useful because it is able to provide further information of clinical value in several cases. In SPECT studies of abdominal diseases, hybrid SPECT/CT can play a role in the differential diagnosis of hepatic hemangiomas located near vascular structures, in precisely detecting and localizing active splenic tissue caused by splenosis in splenectomy patients, in providing important information for therapy optimization in patients submitted to hepatic arterial perfusion scintigraphy, in accurately identifying the involved bowel segments in patients with inflammatory bowel diseases, and in correctly localizing the bleeding sites in patients with gastrointestinal bleeding.

Splenosis mimicking pelvic mass

BACKGROUND

Splenosis is a rare complication after splenectomy and generally does not cause clinical symptoms.

CASE

A 34-year-old woman who had splenectomy in childhood after trauma presented with a pelvic mass. Ultrasound examination demonstrated a right adnexal mass and a myomatous uterus. Exploratory laparotomy revealed multiple splenic implants along the small and large bowel and in the ileocecal region, including the appendix. Total hysterectomy, right salphengectomy, and appendectomy were performed.

CONCLUSION

After splenectomy, splenic implants may mimic benign or malignant tumors of the pelvis and may require surgical exploration.

Occult gastrointestinal bleeding and abdominal pain due to entero-enteric intussusception caused by splenosis

Intussusception is rare in adults. We report the first known case of adult intussusception caused by splenosis. The patient had chronic gastrointestinal bleeding and intermittent abdominal pain. The diagnosis of entero-enteric intussusception was made by CT scan. A laparoscopic-assisted small bowel resection was performed, leading to resolution of the symptoms.

Thoracic splenosis diagnosed by fine-needle aspiration cytology: a case report

A case of thoracic splenosis diagnosed by fine-needle aspiration (FNA) of subpleural lung lesions is presented. The patient, a 49-yr-old male with a history of gunshot wound to his trunk with splenic rupture and splenectomy several years previously, presented with recent hemoptysis and multiple subpleural solid nodules shown in the left lung field by CT scan. As the possibility of a metastatic malignancy vs. mesothelioma was entertained, an FNA was performed on one of these lesions, revealing lymphoid tissue with abundant vascularity simulating the structure of splenic tissue. In view of this finding, supported by the absence of splenic outline in the CT radiograph, the diagnosis of splenosis was made. This is the fourth reported case of thoracic splenosis in which FNA cytology was utilized for diagnosis, yet the first in which the diagnosis was based exclusively on the FNA cytologic findings. Clinical, pathologic, and diagnostic aspects of this entity are discussed.