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

Splenic torsion, a challenging diagnosis in an adult presenting with acute abdomen

INTRODUCTION

Wandering spleen (WS) is a rare condition, occurring in only 0.2 % of cases, where the spleen becomes hypermobile due to the absence or laxity of its anchoring ligaments. Torsion of the spleen, primarily seen in children but occasionally in adults, is a critical complication that can lead to infarction and is considered a medical emergency.

CLINICAL PRESENTATION

We present a case report of a 50-year-old woman with type 2 diabetes and psychiatric illness presented with 2 days of vomiting, abdominal pain, and dehydration. Physical examination showed a tender mass in the abdomen and imaging confirmed a twisted spleen with a thrombosed splenic vein, leading to a successful emergency splenectomy. The patient had an uncomplicated recovery and was discharged with post-splenectomy protocol.

DISCUSSION

Splenic torsion, a rare occurrence primarily observed in children. Clinical diagnosis is aided by palpable abdominal masses and confirmed by radiological imaging. The gold standard diagnostic tool is contrast-enhanced computed tomography (CT), whereas Ultrasonography (USG) is equally good in early assessment. Early identification is crucial to salvage the spleen. Management options include detorsion, splenopexy, or splenectomy depending on the organ viability. Elective splenopexy has emerged as a proactive measure, particularly in children, to prevent complications.

CONCLUSION

Splenic torsion is a rare but important differential diagnosis in patients presenting with acute abdomen. Early diagnosis and prompt management is necessary to preserve the spleen and to prevent the development of complication. Surgery is often necessary and either splenopexy or splenectomy should be done.

IMAGING MANIFESTATIONS OF WANDERING SPLEEN WITH TORSION

BACKGROUND

A wandering spleen (WS) is a rare clinical entity characterized by a spleen located in the lower part of the abdomen or the pelvic cavity rather than the normal anatomical site. The complications of a wandering spleen include splenic torsion, splenic infarction, and adjacent visceral injury.

CASE REPORT

We present a case of a male patient admitted to the emergency department with vomiting, nausea, and persistent lower abdominal pain. Computed tomography and ultrasound were performed and were used to diagnose a wandering spleen with torsion leading to splenic infarctions. Subsequently, laparoscopic surgery and pathology confirmed this diagnosis. WHY SHOULD AN EMERGENCY PHYSICIAN BE AWARE OF THIS?: Ultrasound and computed tomography scans play a significant role in diagnosing WS and its complications, allowing an emergency physician to establish treatment options for WS.

Diagnosis, management and outcome of splenic torsion; a systematic review of published studies

INTRODUCTION

Splenic torsion is a rare condition but one that many surgeons will encounter once in their career. Management options are varied but due to the rarity of the condition there are no contemporary evidence-based summaries to inform a treating clinician. We aim to describe patterns of presentation and provide an evidence-based guide to the management.

METHODS

A PRISMA structured meta-analysis was conducted of all published cases of splenic torsion and a recent case added from our institution.

RESULTS

408 cases were identified between 1888 and 2021 and a single case added from our institution, 312 cases were sourced from case reports and 96 from 40 case series. 8% of patients had a co-existing congenital anomaly and 28% an identified risk factor for splenic torsion. 82% required emergency surgery. A preoperative diagnosis is becoming more common, reaching 80% in 2020's. While spleen conserving surgery is feasible using a variety of techniques. splenectomy was the definitive management for the majority (82%). On histopatholy no occult disease was identified and a significant number of resected spleens were potentially viable; 32% were reported to be normal or congested and 14% demonstrated only partial or focal necrosis.

DISCUSSION

Despite the significant publication bias implied by the methodology this is a large dataset in a rare condition. Splenic torsion frequently occurs in a premorbid population. The presence of a palpable mass in the context of abdominal pain should increase suspicion and trigger cross sectional imaging. Conservation of the spleen, using the techniques discussed, should be seriously considered.

Surgical Approach of Wandering Spleen in Infants and Children: A Systematic Review

Introduction: Splenopexy has been proposed as the treatment of choice in case of wandering spleen (WS). We report our experience and review the current literature focusing on surgical management and outcomes of children affected by WS. Materials and Methods: Data regarding demographics, clinical manifestations, diagnosis, and treatment of children treated for WS at our Institution were analyzed. Systematic review was registered on Prospero (CRD42018089971). Scientific databases were searched using defined keywords. Articles were selected using predefined exclusion and inclusion criteria. Analysis was conducted adding our center's cases. Results: One hundred sixty-six articles were included in the review, 197 cases were analyzed, 3 of which unpublished. Female/male ratio was 1.5:1 and median age at diagnosis was 8 years. Most frequent clinical manifestation was isolated abdominal pain (42.6%). Torsion of splenic pedicle was diagnosed in 56.3%. Among surgical procedures, 39% underwent splenopexy and 54.8% underwent splenectomy. In case of splenopexy, the most commonly used techniques were using of a mesh (45.5%) or creation of a retroperitoneal pouch (30.9%). In 48.2% of splenopexies, minimally invasive surgery (MIS) was used. Splenopexy was effective in 94.8% (88% considering only cases with a spleen torsion). Conclusion: WS is a rare condition potentially leading to torsion of the spleen. This entity has to be kept in mind as a differential diagnosis in case of abdominal pain. Splenopexy should be the treatment of choice; its success rate in terms of preserved spleens can be affected by the presence of a torted organ. Retroperitoneal pouch or mesh fixation are the most preferred techniques. Authors recommend MIS approach.

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.

Wandering spleen: A rare entity and a diagnostic dilemma

Wandering spleen refers to a spleen that is ectopic in its location contrary to a normal spleen which rests in the left hypochondrium. Although it is a rare clinical entity seen in children, it can also be rarely seen in females of reproductive age group. We present one such case of wandering spleen which was misdiagnosed earlier as a sub-hepatic collection.

Wandering spleen: a rare complication of sleeve gastrectomy

The spleen is an intraperitoneal organ typically located in the left upper quadrant. Ectopic ('wandering') spleen refers to the displacement of the spleen from its normal anatomical location to another region in the abdominal cavity or pelvis. It's a relatively rare condition with no clear aetiology. We present, here, a case of a wandering spleen following sleeve gastrectomy in a 23-year-old female patient, whose spleen, prior to this event, was demonstrated by imaging in a normal anatomical position. A splenectomy was performed, and after an uneventful postoperative period, the patient was discharged. No similar case description was found in the relevant medical literature. Possible causes and decision-making process are discussed. We conclude that the wandering spleen phenomenon should be considered in the differential diagnosis of patients presenting with abdominal pain and new abdominal mass following sleeve gastrectomy.

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.

Wandering spleen with horseshoe kidney a rare occurrence

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Wandering spleen with horseshoe kidney is a rare occurrence with less than 3 cases reported worldwide.

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Delay in diagnosis would result is increased mortality.

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Splenopexy is preferred in children with the exception of grossly infarcted spleen.

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Splenectomy is the treatment of choice in torsion of spleen with infarct.

Introduction

Wandering spleen is a rare clinical entity in itself, with only 2 cases reported thus far when correlated with congenital under-development of the kidney, it usually happens due to under development of its surrounding ligaments. Herein we present a case of wandering spleen with underlying congenital deformity of horseshoe kidney which requires splenectomy due to late presentation.

Presentation of case

A 21 year old lady presented with worsening of chronic abdominal pain for 3 years, associated with nausea and vomiting. Physical examination showed a vague mass located at epigastric region. Consecutively, computed tomography images showed a well-defined, oval, hypoechoic spleen extending from center of abdomen up to epigastric region measuring 15.5 × 13 cm with twisted pedicle. Finally the patient underwent surgical treatment. The intraoperative findings were consistent with computed tomography images. The patient made a full recovery and was discharged well.

Discussion

Wandering Spleen was first described by Van Horne during autopsy back in 1667. Its location is maintained by peritoneal attachments such as lienorenal, splenocolic, splenophrenic, gastrosplenic and phrenicocolic ligaments. Among which, the gastrosplenic ligament and lienorenal ligaments are of greatest significance. Patient with a wandering spleen may present asymptomatic, with a movable mass in the abdomen, or with chronic or intermittent abdominal pain because of partial torsion and spontaneous de-torsion of the spleen as in our case. When feasible especially in young patients, splenopexy should always be the first consideration but however if gross infarct has occurred then splenectomy is inevitable to save the patient.

Conclusion

Wandering spleen is a unique surgical entity moreover when appeared in congruence with horseshoe kidney. Its diagnosis should be made in prompt to prevent splenic infarction and to try to salvage with splenopexy especially in younger population. However in patient where splenic torsion with infarction has occurred, splenectomy would be the treatment of choice.

Wandering Spleen: An Overview

An ectopic (or "wandering") spleen results from abnormal ligamentous laxity failing to fixate the spleen in its normal location in the left upper quadrant. Ligamentous laxity can be acquired due to conditions, such as splenomegaly or pregnancy, but is often congenital. Because of this laxity, there is an elongated vascular pedicle, which is prone to torsion and resultant splenic infarction. These patients generally present with abdominal pain and other nonspecific symptoms making the diagnosis very difficult to make clinically. As such, the radiologist plays a crucial role in the diagnosis and care of these patients, as often the diagnosis is only considered after imaging.

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.

Wandering Spleen: A Rare Diagnosis with Variable Presentation

We present two cases of wandering spleen, one in a 47-year-old woman who presented with constipation, and one in a 3-year-old girl who presented with acute abdominal pain. Wandering spleen is a rare clinical condition characterized by ectopic positioning of the spleen due to abnormal peritoneal attachments including the lienorenal and gastrosplenic ligaments. The spleen can “wander” or migrate into various positions within the abdomen or pelvis due to this ligamentous laxity. The clinical presentation of patients with this entity is variable and can range from an incidental finding to an acute abdomen associated with torsion. Various imaging modalities can be utilized for the diagnosis of this condition.

Wandering spleen, gastric and pancreatic volvulus and right-sided descending and sigmoid colon

Wandering spleen is a rare condition, characterized by a mobile spleen that is attached only by an elongated vascular pedicle, allowing it to migrate to any part of the abdomen or pelvis. Mesenteroaxial gastric volvulus usually occurs in children and may be associated with wandering spleen. Both entities result from abnormal laxity or absence of the peritoneal attachments due to abnormal fusion of the peritoneal mesenteries. Pancreatic volvulus is a very rare anomaly, with only a few isolated case reports described in association with wandering spleen. Anomalous right sided descending and sigmoid colon is a very rare entity and its association with wandering spleen has not been previously reported. We report a case of wandering spleen associated with mesenteroaxial gastric volvulus, pancreatic volvulus and rightward shift of the splenic flexure of the colon and right sided descending and sigmoid colon in a young female.

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.

Torsion in wandering spleen: CT demonstration of whirl sign

Wandering spleen is a rare occurrence. Torsion of the splenic pedicle is the major life-threatening complication of this entity. Preoperative diagnosis is based on radiological investigation. We report two consecutive cases, one adult and one child, in whom torsion in a wandering spleen was diagnosed based on a typical whirled appearance of the splenic vessels on computed tomography. We present a review of computed tomographic appearance of splenic torsion, and emphasize the "whirled appearance" as a specific sign for splenic torsion in wandering spleen.

Left upper quadrant pain: upside down spleen

We present the clinical and imaging findings in a patient presenting with left upper quadrant pain. On plain films, a mass was seen in the left upper quadrant, and on computed tomography (CT), a spleen with a whorled pedicle suggesting torsion was identified. However, it was the coronal reconstruction CT study that definitely showed that the spleen had undergone a 180-degree torsion. We refer to the findings on the coronal CT reconstruction as the "upside down" spleen sign, and it was very helpful in clinching the diagnosis.

Abdominal twists and turns: part 2, solid visceral torsions with pathologic correlation

OBJECTIVE

The solid abdominal viscera are secured in place by various suspensory ligaments. Laxity or incomplete development of these anchoring ligaments can lead to hypermobility and predispose the patient to torsion-related ischemic pathology. The clinical symptoms of solid visceral intraabdominal torsions are nonspecific. A prompt diagnosis is critical to avoid life-threatening consequences of prolonged visceral ischemia. Abdominal torsions are rarely diagnosed clinically, and it is often the responsibility of the radiologist to recognize and make the diagnosis through cross-sectional imaging. This article reviews the imaging spectrum, radiologic-pathologic correlations, and therapeutic implications of solid visceral intraabdominal torsions, including some unusual solid organ and abdominal fat torsions.

CONCLUSION

The clinical presentation of solid visceral intraabdominal torsion is nonspecific and radiologists are relied on to make this diagnosis on cross-sectional imaging studies. Recognition of the predisposing factors and imaging spectrum of intraabdominal torsions is essential to help direct timely intervention in these potentially life-threatening entities.

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.

Postcesarean splenic torsion

OBJECTIVE

Splenic torsion is an exceedingly rare complication in pregnancy. We present a case of acute splenic torsion that manifested after cesarean section and which was successfully treated with laparotomy with splenectomy and partial pancreatectomy.

CASE REPORT

A 35-year-old, gravida 7, para 1, aborta 5, woman presented at our hospital for planned cesarean section at 38 weeks of gestation. Thrombocytopenia was noted antenatally and enlarged spleen with smooth surface and contour was observed at the conclusion of cesarean section. One day after delivery, dyspnea and left upper abdominal pain developed. Abdominal computed tomography showed a huge abscess in the left anterolateral abdomen and bilateral pleural effusion. Acute splenic torsion was highly suspected, but the patient refused surgical intervention until the condition exacerbated 21 days after delivery. Splenic pedicle strangulation with thrombosis, a severely ischemic spleen with rupture and distal pancreatic necrosis were noted during emergent laparotomy. She had an uneventful recovery and was discharged 5 days after left splenectomy and partial pancreatectomy.

CONCLUSION

Splenic torsion is a rare cause of acute abdominal pain during pregnancy or postpartum, and the symptoms vary depending on the degree of torsion. Early involvement of many complementary specialty services enabled early recognition of this rare entity and timely definitive treatment.

[Wandering spleen associated to inflammatory pseudotumor]

Wandering spleen is an uncommon clinical entity accounting for less than 0.5% of all splenectomies performed. It can be an incidental finding in asymptomatic patients or it can be found in patients with acute or chronic clinical presentation due to compression (urinary retention, constipation), alterations in splenic function (thrombocytopenia or hypersplenism), or torsion of a vascular pedicle. Wandering spleen is diagnosed by imaging techniques, usually ultrasound, CT, or MRI. scintigraphy or arteriography can also be useful in cases with inconclusive findings. Although cases of wandering spleen associated to diverse masses (epidermoid cysts, simple cysts, cystic lymphangiomas, and lymphomas) have been reported in the literature, to our knowledge there are no reports of this entity associated to inflammatory pseudotumor. We present the case of a patient with wandering spleen associated to inflammatory pseudotumor.

Acute torsion of the spleen: diagnosis and management

We present a 2-year-old girl with a 24-hour history of abdominal pain, fever, and vomiting. The diagnosis of acute splenic torsion was made by means of color and power Doppler ultrasound. Management of this rare surgical emergency is discussed.

Wandering spleen and its complications in children: a case series and review of the literature

Wandering spleen is an uncommon clinical entity, which rarely affects children and adolescents. It is usually described in adults, especially women of childbearing age. Discussion in the literature has been limited to case reports and small case series. Here the authors present 2 children and 1 adolescent that presented to the authors institution over a 9-month period with complications from a wandering spleen. All 3 patients had very different clinical presentations, and this variety is a constant theme throughout the literature. We also identified an additional 127 cases of wandering spleen in patients younger than 21 years. In this report we discuss the clinical presentations, diagnostic evaluation, treatment options, and clinical outcomes as they relate to wandering spleen.

CT findings in congenital anomalies of the spleen

There is a wide range of congenital anomalies of the spleen. Some are common, such as splenic lobulation and accessory spleen. Other less common conditions, such as wandering spleen and polysplenia, have particular clinical significance. Radiologists need to be aware of the various congenital variants of the spleen in order to recognize clinically important anomalies and to avoid mistaking less significant ones for an abnormality. In this pictorial review, the embryology of congenital anomalies of the spleen as well as their appearance on CT are described, diagnostic pitfalls are identified and complications of the anomalies are discussed.

A pattern-oriented approach to splenic imaging in infants and children

The spleen in infants and children is commonly involved in a variety of pathologic processes. Some of these processes cause isolated splenic disease, whereas others involve the spleen as part of a systemic illness. To facilitate differential diagnosis of splenic abnormalities, a pattern-oriented approach to the imaging evaluation of the pediatric spleen was developed. With this approach, splenic anomalies are categorized as anomalies of splenic shape (clefts, notches, lobules), location (eg, wandering spleen), number (polysplenia, asplenia), or size (splenomegaly, splenic atrophy); solitary lesions (eg, cysts, lymphangiomas, hemangiomas, hamartomas); multiple focal lesions (eg, trauma, infection and inflammation, neoplasms, storage disorders); and diffuse disease without focal lesions (eg, infarction, heavy metal deposition, hemangioendotheliomas, peliosis). A variety of imaging modalities can be used in splenic assessment, including computed tomography, magnetic resonance imaging, ultrasound, and technetium-99m scintigraphy. The imaging appearance of the pediatric spleen depends on the patient's age and the modality used; however, familiarity with the spectrum of radiologic patterns of splenic involvement will facilitate correct diagnosis and prompt treatment.