Torsion of a wandering spleen as cause of sudden onset abdominal pain

A 40-year-old woman without past medical or surgical history presented with one-day history of a sudden onset severe left-sided abdominal pain, intermittent, radiating to the left shoulder and associated with 2 episodes of vomiting. Abdominal examination revealed a generalised rigidity, and tenderness in the left upper and lower quadrants. Laboratory results showed leucocytosis.

Contrast-enhanced computed tomography (CT) of the abdomen and pelvis showed absence of a normal spleen in the left subphrenic space. The spleen had migrated inferiorly into the abdomen with torsion at the vascular pedicle and infarction of the spleen (an incidental dextrocardia was found).
The patient underwent an emergency open splenectomy. The spleen was discovered to be freed from all of its usual attachments and the only attachment was the torsed vascular pedicle.The spleen was torsed and infarcted. The operation went smoothly, and the patient was discharged after a short hospital stay.

Wandering spleen (WS) is a rare entity in which absence or laxity of the spleen's peritoneal attachments resulting in unusual location within the peritoneal cavity and predisposing to complications such as torsion and infarction. Incidence is unknown, but it accounts for 0.2-0.3% of splenectomies.
WS could be:
- congenital - usually seen in children
- or acquired - usually seen in young women between ages 20-40.
WS is difficult to diagnose clinically as individuals with WS may remain asymptomatic or present with non-specific symptoms ranging from intermittent abdominal pain to acute abdominal emergencies. Diagnosis of WS is nearly impossible without imaging studies, in which the diagnosis is suggested by the absence of the spleen in the left subphrenic space or an abnormal orientation in the left upper quadrant and the presence of an ectopic spleen-like mass, with a long vascular pedicle that often is tortuous. [1, 2]
Different imaging modalities are used in the diagnosis of WS, however, contrast-enhanced computed tomography (CT) and ultrasonography (US) are the main tools.
US is mainly used to asses the viability of the spleen by using Doppler ultrasound that shows the vascular flow pattern. It is easily available and a comparatively safe technique. There are several disadvantage include difficulty to delineate the anatomic relationships, torsion of the pedicles and revealing associated complications.
CT scan is the best imaging tool to diagnose WS. It allows confirmation of WS and exclusion of other pathologies. It shows the exact abnormal location of the spleen and demonstrates the anatomic position of other abdominal structures, and reveals associated complications such as torsion and infarction. [3, 4]
Most common findings on CT include:
- Abnormal location of the spleen in the abdomen/pelvis or abnormal orientation of the spleen in the left upper quadrant
- whirl/corkscrew sign of the torsed pedicle
- lack of enhancement of splenic parenchyma following injection of contrast in case of infarction
Once the diagnosis is made, surgery is the only definitive treatment for WS. Management is either splenectomy or splenopexy.
Splenectomy is the preferred treatment in patients with acute splenic infarction due to complete pedicle torsion.
Splenopexy is preferred in children and in cases with a non-infarcted wandering spleen or minimal degree of torsion. [1, 4]