Torsion of the wandering spleen as an abdominal emergency: a case report

Hidden for years: Torsion and infarction in the wandering spleen of a 45-year-old woman

INTRODUCTION AND IMPORTANCE

Wandering spleen (WS), characterized by abnormal mobility due to laxity of its ligaments, is a rare condition often presenting diagnostic challenges. Its complications, such as torsion and infarction, necessitate prompt recognition and management to prevent life-threatening outcomes.

CASE PRESENTATION

We report a case of a 45-year-old female presenting with acute abdominal pain, constipation, and a palpable mass in the right iliac fossa. Imaging revealed a torsion of a wandering spleen, a rare occurrence exacerbated by delayed diagnosis despite a decade of symptoms.

CLINICAL DISCUSSION

Diagnostic imaging, including abdominal ultrasound and CT scan, played a crucial role in confirming the ectopic spleen and guiding surgical intervention. Immediate laparotomy revealed a twisted spleen necessitating splenectomy due to non-viability post-detorsion attempt.

CONCLUSION

This case underscores the importance of considering wandering spleen in the differential diagnosis of acute abdominal pain, especially in patients with chronic intermittent symptoms. Surgical intervention remains the definitive treatment, emphasizing the risks associated with conservative management in preventing complications.

Wandering spleen presenting in the form of right sided pelvic mass and pain in a patient with AD-PCKD: a case report and review of the literature

BACKGROUND

Wandering spleen is a rare clinical entity in which the spleen is hypermobile and migrate from its normal left hypochondriac position to any other abdominal or pelvic position as a result of absent or abnormal laxity of the suspensory ligaments (Puranik in Gastroenterol Rep 5:241, 2015, Evangelos in Am J Case Rep. 21, 2020) which in turn is due to either congenital laxity or precipitated by trauma, pregnancy, or connective tissue disorder (Puranik in Gastroenterol Rep 5:241, 2015, Jawad in Cureus 15, 2023). It may be asymptomatic and accidentally discovered for imaging done for other reasons or cause symptoms as a result of torsion of its pedicle and infarction or compression on adjacent viscera on its new position. It needs to be surgically treated upon discovery either by splenopexy or splectomy based on whether the spleen is mobile or not.

CASE PRESENTATION

We present a case of 39 years old female Ethiopian patient who presented to us complaining constant lower abdominal pain especially on the right side associated with swelling of one year which got worse over the preceding few months of her presentation to our facility. She is primiparous with delivery by C/section and a known case of HIV infection on HAART. Physical examination revealed a right lower quadrant well defined, fairly mobile and slightly tender swelling. Hematologic investigations are unremarkable. Imaging with abdominopelvic U/S and CT-scan showed a predominantly cystic, hypo attenuating right sided pelvic mass with narrow elongated attachment to pancreatic tail and absent spleen in its normal position. CT also showed multiple different sized purely cystic lesions all over both kidneys and the pancreas compatible with AD polycystic kidney and pancreatic disease. With a diagnosis of wandering possibly infarcted spleen, she underwent laparotomy, the finding being a fully infarcted spleen located on the right half of the upper pelvis with twisted pedicle and dense adhesions to the adjacent distal ileum and colon. Release of adhesions and splenectomy was done. Her post-operative course was uneventful.

CONCLUSION

Wandering spleen is a rare clinical condition that needs to be included in the list of differential diagnosis in patients presenting with lower abdominal and pelvic masses. As we have learnt from our case, a high index of suspicion is required to detect it early and intervene by doing splenopexy and thereby avoiding splenectomy and its related complications.

Wandering spleen in a postpartum female: a case report

Introduction and importance

Wandering spleen (WS) is a rare condition that occurs when the spleen is not in its normal anatomical location, but in the abdominal or pelvic cavity. The mechanism of this condition may be due to dysfunction of ligaments that fixate the spleen in its position. Female hormonal alterations during pregnancy and other unknown causes in children may also play role in an ectopic spleen.

Case presentation

The authors report a case of a 34-year-old woman who presented to the emergency department with intermittent abdominal pain that persisted after childbirth without other symptoms.

Clinical discussion

Clinically the symptoms are varied and abdominal pain is the most common presentation. Radiological investigation of WS include ultrasound, MRI, and CT, which is the most preferred tool. Treatments after the diagnosis include splenectomy or splenopexy either through laparoscopy or laparotomy.

Conclusion

Physicians should include ectopic spleen as a differential diagnosis in a multiparous woman with the presentation of acute or chronic abdominal pain.

Splenic torsion mistaken for an ovarian cyst: a case report

BACKGROUND

Wandering spleen (or ectopic spleen) refers to a hyper-mobile spleen resulting in its displacement from the normal anatomical position to usually in the lower abdominal or pelvic cavity. While ultrasound is often the first radiological modality used, Computed Tomography (CT) shows a clear picture and aides to reach a diagnosis. In circumstances where appropriate imaging modalities are not available, or the operator is inexperienced, diagnosis of wandering spleen can be missed.

CASE PRESENTATION

A 22-nulligravida unmarried Sindhi female had presented to the Emergency Room (ER) with a 5-day history of intermittent severe lower abdominal pain. An ultrasound at a local practitioner had suggested an ovarian cyst. Ultrasound-pelvis and later CT scan at our facility reported an enlarged wandering spleen with torsion of its pedicle and infarction. Exploratory laparotomy with splenectomy was done. An enlarged wandering spleen was found with torsion of the splenic vein and thrombosed arterial supply from omentum wrapped over the mass. The patient developed thrombocytosis post-surgery but otherwise did well and was discharged after 2 days.

CONCLUSION

Splenic torsion secondary to a wandering spleen can be challenging to diagnose, especially in resource limited settings where ultrasound might be the only modality available. Timely diagnosis and proper intervention are key to saving the life and the spleen.

Laparoscopic exploration of a wandering spleen in a complex adolescent case with sigmoid volvulus and left-side portal hypertension: a case report

Wandering spleen (WS) is a rare condition characterized by the hypermobility of the spleen due to the absence or abnormal flexibility of suspensory ligaments. We present a 16-year-old female presented with intermittent abdominal pain, constipation, and a palpable mass in the right iliac fossa. Imaging revealed a WS associated with sigmoid volvulus and portal hypertension. Despite a decade of symptoms, the patient remained undiagnosed. Laparoscopic splenectomy was performed successfully, addressing both WS and sigmoid volvulus. The patient's symptoms resolved, and she was discharged in good condition. This case emphasizes the need for clinical awareness of WS in the differential diagnosis of abdominal pain. It highlights the role of imaging in prompt diagnosis and the necessity of surgical intervention. Our case sheds light on the association of WS with other conditions, providing clinicians with valuable insights for effective management.

Wandering Spleen After Sleeve Gastrectomy as a Cause of Sigmoid Volvulus

The report highlights a rare instance of colonic volvulus due to a wandering spleen. Wandering spleen is characterized by the displacement of the spleen due to absent or weakened ligaments due to congenital factors or acquired factors such as pregnancy or prior surgery leading to ligament disruption. The 26-year-old patient presented with severe abdominal pain and distention, leading to a diagnosis of sigmoid volvulus secondary to the wandering spleen. This case underscores the importance of considering the wandering spleen in the differential diagnosis of acute abdomen, especially in patients with a surgical history of gastric sleeve resection. The article emphasizes the critical role of imaging in diagnosis and the necessity of timely surgical intervention to prevent severe complications. The case contributes to a broader understanding of the wandering spleen, particularly in post-surgical contexts, highlighting diagnostic challenges and management strategies.

A wandering spleen with 720° torsion and persistent ascending and descending mesocolon in a 5-year-old Syrian male: A case report

INTRODUCTION AND IMPORTANCE

The spleen is normally found in the left hypochondrium and it is fixed in its place by numerous suspensory ligaments. When the ligaments are elongated or abnormally developed, it causes a rare medical condition called Wandering spleen. A persistent ascending and descending mesocolon is also a congenital anomaly, resulting from the failure of fusion of the primitive dorsal mesocolon.

CASE PRESENTATION

Herein, a 5-year-old male child with sudden and acute onset of abdominal pain, constipation, nausea, tachycardia, and low urine output, imaging and blood tests revealed evidence of intestinal obstruction and normocytic anemia and neutrophilia. A laparotomy revealed persistent ascending and descending mesocolon, with a torsioned vascular pedicle of the spleen, resulting in splenomegaly and infarction. The surgeon successfully derotated the torsioned pedicle and performed a splenectomy. The patient had an uneventful postoperative course and was discharged without complications.

CLINICAL DISCUSSION

This case could be asymptomatic and the diagnosis is incidental or it could be presented with ambiguous symptoms. The differential diagnosis of WS varies according to the clinical presentation and the associated complication. For instance, in the case of WS torsion and acute presentation, the differential diagnosis is ovarian torsion, acute appendicitis, and intestinal obstruction. Currently, surgery is the only suggested treatment option even in asymptomatic patients as well.

CONCLUSION

This case of a Wandering Spleen is associated with a persistent ascending and descending mesocolon, suggesting that there may be certain risk factors. Therefore, we suggest making more research about wandering spleen in association with persistent mesocolon.

Wandering Spleen: A Rare Case From the Emergency Department

The spleen is typically located in the left upper quadrant and is held in position by the suspensory ligaments, which include the gastrosplenic ligament, the splenorenal ligament, and the phrenicocolic ligament. Abnormalities within these ligaments result in the mobility of the spleen, so it may be located in the pelvis or iliac region, which is termed a wandering spleen. We present a case of a middle-aged man who presented to the emergency department with generalized abdominal pain and diffuse guarding and tenderness. The patient had a previous history of peptic ulcer disease and multiple emergency department visits for gastritis. Given the assumed diagnosis of perforated viscus, the patient underwent a computed tomography scan that demonstrated the absence of the spleen in its usual location and showed an ectopic pelvic spleen. The patient underwent successful surgical treatment with splenopexy. The wandering spleen is a rare medical condition that presents a clinical diagnostic challenge and requires a high index of suspicion. Despite its rarity, the wandering spleen should be considered in patients with recurrent abdominal pain.

Diagnosis and treatment of splenic torsion in children: preoperative thrombocytosis predicts splenic infarction

Background

Pediatric splenic torsion is a rare entity, and the most common cause is wandering spleen. This study aimed to summarize our clinical experience in the diagnosis and surgical treatment pediatric patients with splenic torsion, and to use preoperative thrombocytosis as a preoperative predictive factor for splenic infarction.

Methods

From January 1st, 2016 to December 31st, 2021, 6 children diagnosed as splenic torsion were included. All patients were surgically treated and followed up. The clinical data was collected including clinical presentations, laboratory tests, imaging results, surgical procedures, and prognosis. Clinical experience of diagnosis and surgical treatment were summarized.

Results

There were 4 females and 2 males, with median age at surgery 102.6 (range 9.4–170.7) months. Abdominal pain and abdominal mass were the most common presentations. The diagnosis of splenic torsion depended on imaging studies, and adjacent organ involvement (gastric and pancreas torsion) was observed on contrast CT in one patient. Five patients were diagnosed as torsion of wandering spleen, and one was torsion of wandering accessory spleen. Emergent laparoscopic or open splenectomy was performed in all patients. Pathology revealed total splenic infarction in 4 patients, partial infarction in 1 patient, and viable spleen with congestion and hemorrhage in 1 patient. Preoperative platelet counts were elevated in all 4 patients with splenic infarction, but normal in the rest 2 with viable spleen. Postoperative transient portal vein branch thromboembolism occurred in one patient.

Conclusions

Imaging modalities are crucial for the diagnosis of pediatric splenic torsion and adjacent organ involvement. Preoperative thrombocytosis may predict splenic infarction. Spleen preserving surgery should be seriously considered over splenectomy in patients with a viable spleen.

Supplementary Information

The online version contains supplementary material available at 10.1186/s12887-022-03484-y.

Torsion of a Wandering Spleen Involving the Pancreatic Tail and Splenic Flexure and Isolated Left-Sided Portal Hypertension due to Chronic Splenic Vein Thrombosis

Wandering spleen is a rare entity, wherein the spleen is attached only by an elongated vascular pedicle, predisposing it to complications like hilar torsion, infarction, rupture, etc. Pancreatic volvulus is another very rare anomaly, with isolated case reports described in association with wandering spleen. The presentation varies from asymptomatic lump (stimulating a mass) to acute abdomen (due to torsion). We present a case of 26-year-old female patient who complained of pain in abdomen, and was radiologically diagnosed and surgically confirmed to have a torsion of wandering spleen with involvement of pancreatic tail and splenic flexure. Few cases with associated finding of gastric volvulus and sigmoid volvulus have been described previously. Involvement of descending colon in a 9-year-old child has been reported. However, to the authors' knowledge, this is the first case report describing the combination of wandering spleen with splenic flexure and pancreatic tail involvement in an adult.

Wandering spleen torsion in a patient with polysplenia syndrome

Polysplenia Syndrome is a rare condition that refers to the presence of 2 or more spleens in association with other thoracoabdominal abnormalities. Here, we report a case of a 13-year-old girl who presented with acute lower abdominal pain and was diagnosed with polysplenia syndrome after obtaining a CT scan of her chest, abdomen and pelvis. Diagnostic imaging also revealed the presence of a wandering spleen hanging in the lower abdomen and upper pelvic cavity and showing signs of infarction. The patient underwent splenectomy afterward and splenic torsion was confirmed intraoperatively. To the best of our knowledge, this was the first reported case of wandering spleen torsion in a patient with polysplenia syndrome. Physicians should keep in mind the possibility of a wandering spleen torsion presenting in various locations when dealing with polysplenia syndrome patients complaining of abdominal pain.

Wandering spleen with torsion: a rare cause of acute abdomen in a 14-year-old girl

Wandering spleen is a rare condition and defined as the spleen that is not in its normal anatomical position due to lack or laxity of suspensory ligaments. Etiological factors are congenital and acquired. Splenic torsion, infraction, and rupture are life-threatening complications of wandering spleen. A 14-year-old girl patient presented to the emergency department with severe pain abdomen for 2 days. On physical examination, a large palpable mass in the mid of the abdomen was found, and CECT confirmed it as torsion of wandering spleen. Emergency exploration is done and splenectomy was done due to non-viability of the spleen. The Post-op period was uneventful. Acute torsion of wandering spleen is an extremely rare clinical entity and patient present in an emergency with clinical features of acute abdomen. They may also present with chronic pain abdomen and abdominal mass. Early diagnosis is vital for the preservation of the spleen. Radiological studies have an important role in an accurate diagnosis. Surgery is the gold standard treatment of wandering spleen. Surgery for splenopexy or splenectomy depends on the condition of the spleen during surgery. Timely diagnosis and interventions are crucial to prevent life-threatening complications of wandering spleen.