QUESTION
A 22-year-old unmarried woman with history of mitral valve repair for VSD in the childhood presented with complaints of rolling movement in the abdomen from the left to right side. For the last 1 month, she observed a disappearing mass in her abdomen with associated occasional pain. Her complete blood count, RFT, and LFT were normal. An abdominal ultrasound was done followed by an abdominal and pelvic CT scan (Figure 1, 2). What does the figure show?
Figure 1.
CT scan saggital view
Figure 2.
CT scan sagittal view with oral contrast
ANSWER
Wandering spleen
The CT scan revealed that the spleen was not visualized in the splenic fossa. Mobile spleen was located in the lower abdomen with a long vascular pedicle and no evidence of any infarction. In view of pain and chance of torsion, laparoscopy was planned. Intraoperatively, there was a three and a half twist of the splenic vascular pedicle and presence of a splenic infarct.
While trying to derotate the spleen, there was a capsular tear, which caused bleeding and obscured the field of vision. Hence, minilaparotomy and splenectomy were performed.
Histopathological study showed congested spleen with reactive lymphnodes. Patient was discharged after giving triple vaccination and being instructed about postsplenectomy infections.
Wandering spleen is a rare clinical entity found due to the ectopic location of the spleen in the abdominal cavity and abnormally high mobility due to long vascular pedicles. The rate of occurrence is <5% in all splenectomized patients with a total of 500 cases reported till now (1). The incidence is equal in both sexes. Mostly, it is an incidental finding. Clinically, we can suspect if the following is found:
Feeling of a notch over the mass
Empty left upper quadrant on palpation
Resonant left upper quadrant on percussion
Intermittent pain
Disappearing mass in the abdomen
The treatment of choice depends on the status of the vessels and splenic viability. Though conservative treatment is advised for some patients, the chances of complications are high up to 65% (2). In the surgical corundum, the procedures include splenopexy or splenectomy. These procedures can be done either laparoscopically or with laparotomy.
In conclusion, wandering spleen can be diagnosed with a high index of suspicion in a disappearing abdominal mass, which can be confirmed with modern imaging modalities such as ultrasound and CT scan. Surgery is the definitive treatment.
Figure 3.
Twisted splenic vasculature
Figure 4.
Resected spleen
Footnotes
Peer-review: Externally peer-reviewed.
Conflict of Interest: The authors have no conflict of interest to declare.
Author Contributions: Concept – A.K.S., M.G., S.R., R.R., V.P.; Design - A.K.S., M.G., S.R., R.R., V.P.; Supervision - A.K.S., M.G., S.R., R.R., V.P.; Materials - A.K.S., M.G., S.R., R.R., V.P.; Data Collection and/or Processing - A.K.S., M.G., S.R., R.R., V.P.; Analysis and/or Interpretation - A.K.S., M.G., S.R., R.R., V.P.; Literature Search - A.K.S., M.G., S.R., R.R., V.P.; Writing Manuscript - A.K.S., M.G., S.R., R.R., V.P.; Critical Reviews - A.K.S., M.G., S.R., R.R., V.P.
Financial Disclosure: The authors declared that this study has received no financial support.
REFERENCES
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