Splenic haemorrhage in a newborn as the first manifestation of wandering spleen syndrome

Splenic rupture presenting with marked scrotal ecchymosis in a 2-day-old newborn

Splenic rupture is a rare and severe condition in neonates. The signs and symptoms are vague and non-specific and are often not recognised before the onset of hypovolaemic shock or death. A 2-day-old infant presented with scrotal ecchymosis, and ultrasonography detected haemorrhage in the scrotal, right inguinal and adrenal regions. Computed tomography demonstrated a peri-splenic haematoma. Haemoglobin (Hb) was 2.79 g/dL and, despite repeated transfusions, the Hb level could not be sustained. Exploratory laparotomy detected a large haematoma in the splenic region, and, because of the uncontrolled haemorrhage, splenectomy was required.

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 Results: One hundred sixty-six articles were included in the review, 197 cases were analyzed, 3 of which unpublished.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.

Prognostic Factors and Clinical Features of Neonatal Splenic Rupture/Hemorrhage: Two Cases Reports and Literature Review

Background: Neonatal splenic rupture/hemorrhage (SRH), an extremely rare and potentially fatal presentation, can spontaneously resolve without surgical treatment; However, treatment approaches remain controversial. The present study aimed to describe and analyze the clinical features and therapies of neonatal SRH and therapeutic approaches. Methods: We present the cases of two patients and review another 37 cases reported in English-literature. The literature search included all articles published in PUBMED from inception between January 1968 and December 2019. Demographic data, precipitating factors, clinical characteristics including presenting symptoms and signs, presenting time, age at SRH presentation, imaging findings, as well as treatments and outcomes were analyzed. Results: In addition to the two cases treated at our hospital, 37 neonates with SRH were reported during the study period. The rate of full-term neonates was 72% (28/39). The cause was idiopathic in most cases, and congenital coagulation disorders were underlying causes in 13% (5/39) of the cases. The most common presenting symptom and sign of neonatal SRH were pallor or anemia, followed by abdominal discoloration/distension. Additionally, 18% (7/39) of the cases presented with scrotal hematoma or swelling. The age at SRH presentation ranged between 3 h and 5 days of age. Abdominal ultrasonography or computed tomography was used as the diagnostic tool. Twenty-seven cases (69%) received surgical management. The prognosis was comparable between the neonates treated with splenectomy and those treated with non-surgical approaches. The mortality rate was 18% (7/39) in the study cohort. SRH presentation at ≤12 h of age was associated with higher mortality compared to SRH presenting time at >12 h of age (odds ratio 25.0, 95% CI 2.514-248.575, p = 0.001). Conclusion: Our literature review revealed that the mortality rate of neonatal SRH was 18% and that the mortality risk was higher in neonates presenting with SRH symptoms and signs at ≤12 h of age.

Early hypovolemic shock and abdominal distention due to neonatal splenic rupture: urgency of diagnosis and management

Splenic rupture in the neonatal period is a rare condition that can be complicated by hemorrhagic shock. The symptoms are not very specific, rendering the diagnosis difficult and often delayed; sometimes only discovered at autopsy. We report five cases diagnosed in the Rhône-Alpes region of France. From these observations and from a review of the literature, the circumstances of the occurrence, the clinical signs, and the therapeutic possibilities are discussed. In the presence of severe anemia with pallor and abdominal distension, particularly in the context of a difficult birth, an abdominal ultrasound must be urgently performed and surgical management promptly considered.

CONCLUSION

This pathology must be known to the neonatologist so that she/he can quickly evoke it, given that it can quickly become life-threatening. What is known: • Splenic rupture in the neonatal period is a rare condition that can be complicated by hemorrhagic shock and quickly lead to the death of the newborn. • The symptoms are not very specific, rendering the diagnosis difficult and often delayed. What is new: • This is the first publication bringing together as many clinical cases on the subject reporting in particular very serious cases to alert the clinician on this pathology and its diagnostic urgency. • We propose a clear therapeutic behavior to help the clinician in his daily practice.

The Great Pretender: Pediatric Wandering Spleen: Two Case Reports and Review of the Literature

Wandering spleen is a rare condition, typically not only due to embryological defects of the splenic ligaments, but also secondary to trauma and splenomegaly. The most common presentation is acute abdomen with a mobile abdominal mass or recurrent abdominal pain. However, the spleen may be temporary in its normal position, and patients could be asymptomatic. A familiarity, if present, strengthens the diagnostic suspect.Abdominal ultrasonography and computed tomography are the examination of choice, and the management is surgical.

Spontaneous Splenic Hemorrhage in the Newborn

Spontaneous splenic hemorrhage in the newborn is a rare entity. The presentation is usually with a triad of bleeding, abdominal distension, and hemoperitoneum. Rapid diagnosis is essential as left untreated, death is inevitable. We present a case with an unusual initial presentation of a scrotal hematocele and ultrasonography suggesting an adrenal hemorrhage. At laparotomy, splenic preservation was unsuccessful, and therefore, splenectomy was performed. The child recovered well from the procedure.

Wandering spleen in children: a report of 3 cases and a brief literature review underlining the importance of diagnostic imaging

BACKGROUND

Wandering spleen is a rare condition in children that is often caused by loss or weakening of the splenic ligaments. Its clinical presentation is variable; 64% of children with wandering spleen have splenic torsion as a complication.

OBJECTIVE

To provide up-to-date information on the diagnosis, clinical management and diagnostic imaging approaches for wandering spleen in infants and children and to underline the importance of color Doppler US and CT in providing important information for patient management.

MATERIALS AND METHODS

We report a series of three children with wandering spleen treated at our children's hospital over the last 6 years. All three underwent clinical evaluation, color Doppler US and CT and were surgically treated. We also reviewed 40 articles that included 55 patients younger than 18 years reported in the Medline database from 2002 to 2012.

RESULTS

We correlated pathological data with imaging findings. Color Doppler US, the first imaging modality in investigating abdominal symptoms in children with suspected wandering spleen, yielded a diagnostic sensitivity of 54.9%, whereas CT achieved about 71.7%.

CONCLUSION

Radiologic evaluation has a major role in confirming the diagnosis of a suspected wandering spleen and avoiding potentially life-threatening complications requiring immediate surgery.

Multimodality imaging of a neonatal wandering spleen

Wandering spleen, a rare entity, is caused by the absence or laxity of the normal anchoring splenic ligaments. Only three neonatal cases have been reported in the English-language literature. We present the clinical and multimodality imaging findings of a newborn with laceration and hemorrhage of a wandering spleen. The course was complicated by the concurrent diagnosis of glucose-6-phosphate dehydrogenase deficiency, which confused the clinical picture when a falling hematocrit raised the question of rebleeding several days after presentation.

Splenic rupture in a newborn with severe hemophilia--case report and review

Life-threatening splenic rupture is rare in neonates with severe hemophilia. There are only 3 cases of splenic rupture in neonates with hemophilia reported in the literature. We present the case of an infant, born to a hemophilia A carrier mother. The infant was asymptomatic until discharge at 48 hours of age, but presented on the third day of life with shock, abdominal distension, and severe anemia. Computed tomography of the abdomen confirmed the diagnosis of splenic rupture with hemoperitoneum. The infant recovered after extensive supportive care surgery and factor replacement.

Laparoscopic splenopexy for a wandering spleen in a child

We present a case of acute volvulus of a wandering spleen in a 5-year-old girl that was diagnosed preoperatively by computed tomography scan and which we treated with a laparoscopic splenopexy on an emergent basis.

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.

[Neonatal splenic injury: a difficult diagnosis]

Neonatal splenic injury is a rare but serious condition, due to the risk of haemorrhagic shock. We report on the case of a newborn infant with a neonatal respiratory distress that first evoked materno-fetal infection. Clinical deterioration, with anemia and abdominal distension, led then to the proper diagnosis. Dystocia seems to be the most likely cause of the splenic rupture in this report. Medical treatment is advocated as first line, while surgical treatment may be necessary in some cases. In the case surgery is inevitable, a conservative approach is preferable.

Splenoptosis complicated by a large splenic cyst: case report and discussion of combined management

Splenoptosis is a rare condition in children. Its association with a cyst is rare. A case of splenoptosis complicated by a large cyst is reported. The child presented with features of intermittent abdominal pain, constipation and clinical examination revealed a mass apparently rising out of the pelvis. Ultrasound confirmed the mass as spleen with a 15 cm cyst in the lower pole. At surgery the cyst was marsupialised and splenopexy undertaken placing the cyst in a retro-peritoneal pouch. This is only the second report of such a case in the English literature.

[Torsion of the spleen in children]

The wandering spleen is caused by congenital absence of fixating ligaments or abnormally long ligaments. It is an uncommon clinical entity, which rarely affects children. The clinical presentation of wandering spleen is variable, but the most dangerous complication is splenic torsion. A 7 year-old boy presented with abdominal pain and vomiting. The abdominal ultrasound scan discovered spleen ischemia. Volvulus of the spleen was evoked. Laparotomy was carried out and the patient underwent splenectomy. In this case the anatomical means of spleen fixity were absent. Because wandering spleen is uncommon in the paediatric population, a heightened awareness of the condition is required for accurate diagnosis and appropriate management. The treatment of choice is splenopexy, while if splenic necrosis is present, splenectomy is required.