Abdominal imagingCase Type
Rajendrakumar N L, Nanjaraj C P, Pradeep H N, Chandana V, Sanjay P, Tanuja Ponnappa C, Prathibha P S, Tilaka, Priyanka S VPatient
16 years, female
A 16-year-old female presented to us with sudden onset of abdominal pain. No similar complaints in the past. The patient was febrile with mild pallor and stable vitals. On abdominal examination, mild distension of abdomen with diffuse tenderness and guarding was noted. Laboratory investigations showed mild anemia.
The erect radiograph of the abdomen showed absence of normal splenic shadow. Few gas-filled bowel loops were seen occupying the splenic fossa in the left upper quadrant (fig 1).
Ultrasonography (USG) of the abdomen showed a large heterogeneous solid mass in the left iliac fossa, which on Doppler showed no internal vascularity. Spleen was not visualised in its anatomic location (fig 2a,2b).
On Contrast-enhanced computed tomography (CECT) of the abdomen, the ectopic location of spleen was confirmed, which was seen inferiorly in left iliac fossa and infra umbilical region (fig 3). Surrounding mesenteric haziness noted. Heterogeneous enhancement of spleen was noted with few non-enhancing areas within (fig 4a,4b). Twisting of the vascular pedicle was noted - “whirl sign” (fig 5a,5b).
Radiological diagnosis of the torsed wandering spleen with infarcts was made.
The patient underwent emergency laparotomy, the diagnosis was confirmed, detorsion and splenopexy was done (fig 6a, 6b).
Wandering spleen, also called as the ectopic or floating spleen is a rare entity in which the spleen is seen outside its normal anatomical location, can be seen anywhere in the abdomen depending on the length of its vascular pedicle. Its incidence is lower than 0.5% and is mostly seen in children and females of 20-40 years .
Wandering spleen is caused due to congenital absence, maldevelopment, or laxity of the supporting ligaments like the gastrosplenic, the splenorenal, and the phrenicocolic ligaments [1,2].
Because of this abnormal laxity, the elongated vascular pedicle is highly prone to complications like torsion, infarction, or gangrenous changes of the spleen. Most of the patients present with abdominal pain or as asymptomatic mass and other nonspecific symptoms, making the clinical diagnosis difficult. Thus, imaging plays a very important role [3,4].
Several imaging modalities have been used for diagnosis, like conventional radiography, barium studies, USG, CECT, radionuclide studies, and angiography .
Plain abdominal radiographs, usually have nonspecific findings but can show an absence of normal splenic shadow and numerous gas-filled bowel loops occupying the splenic fossa in the left upper quadrant, there can also be a mass in the central abdomen or left flank [5,6].
Ultrasonography is the initial investigation of choice, which shows the typical ectopic location of the spleen and with duplex imaging vascularity can be evaluated, but has disadvantages: it is operator dependent and bowel gases can obscure the findings [5,6].
CECT is the preferred modality of choice . The characteristic finding includes the absence of spleen in its normal anatomical location and often seen as a “comma” shaped mass in an ectopic location. Tracing the course of the splenic vessels can show swirling of the vascular pedicle giving “whirl sign” which is the most specific sign of splenic torsion . Other findings include abnormal enhancement of the spleen, vascular engorgement, thrombosis of splenic vein, ascites, and surrounding fat stranding [3,7,8]. Additionally, a hyperdense splenic capsule compared to the parenchyma is referred as-‘‘rim’’ sign, which suggests splenic infarct can be seen . On post gadolinium magnetic resonance imaging similar inhomogeneous enhancement is seen . Tc-99m sulfur colloid imaging and angiography can be used although not usually indicated .
The treatment includes either splenectomy or detorsion with splenopexy. Preservation of spleen is recommended in young patients because of the increased risk of post-splenectomy sepsis .
Written informed patient consent for publication has been obtained.
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