Case 12042

Wandering Spleen

Simões, André; Lopes, Pedro; Viamonte, Bárbara.

Section: Abdominal Imaging

Published: 2014, Sep. 16
Patient: 15 year(s), male

Authors' Institution
Rua Mestre Guilherme Camarinha n150 Hab 3.4 4200 Porto, Portugal;
Email:andre.silva.simoes@gmail.com

Clinical History
A 15-year-old boy presented to the emergency department with diffuse abdominal pain and
vomiting. The patient denied previous episodes of similar pain. Physical examination revealed a
distended abdomen, diffusely tender to palpation, with a palpable mass in the lower quadrants.
Ultrasound and computed tomography were made.

Imaging Findings
Ultrasound (images not available) revealed a hypoechogenic and slightly heterogeneous mass in the
right lower quadrant of the abdomen and a small quantity of peritoneal free fluid. Additional color
Doppler study showed no vascularization within the mass. Spleen wasn't identified in its anatomic
position.
CT images (Fig 1 - 3) was then preformed confirming the presence of a hypodense, slightly
heterogeneous mass in the right lower quadrant. Some vessels with whorled appearance (Fig 1 and
2) were depicted arising from the proximity of the celiac trunk and entering the mass. This
corresponded to a twisted vascular pedicle of the spleen.

Discussion
 Wandering spleen is a rare clinical condition characterized by a hypermobile spleen. Absence or
laxity of the normal splenic ligaments, leads to the development of long vascular pedicle, which
contributes to splenic hypermobility and higher torsion risk. [1, 2, 3] Causes can be congenital or
acquired (splenomegaly, pregnancy or trauma). [1, 4, 5]
Wandering spleen is usually an isolated condition however, in rare cases, it can be associated with
diaphragmatic hernia and gastric volvulus. [2, 6]
Clinical presentation is nonspecific and may vary depending on the degree of torsion, presenting as
an incidental mass on physical examination, mild abdominal pain due to vascular congestion or
acute abdomen due to torsion of the splenic pedicle with infarction. [1, 3] Pain is secondary to
capsular stretching and local peritonitis. [1]
Clinical diagnosis is extremely difficult and imaging evaluation is usually needed. Imaging
modalities such as plain abdominal radiography, ultrasound with Doppler study and computed
tomography (CT) are commonly used to make the diagnosis. [2, 3, 4] Absence of spleen in its
anatomic position and twisted vascular pedicle of the spleen are important imaging features.
Splenic torsion treatment is usually surgical. Splenopexy is the preferred technique, but its only
possible when spleen vascularization is preserved. When splenic infarction is present, splenectomy
is the indicated procedure. [2, 4, 7]

Final Diagnosis
Wandering Spleen Torsion

Differential Diagnosis List

Acute appendicitis, Meckel diverticulitis, Intussusception, Mesenteric cyst with small bowel
volvulus

Figures

Figure 1 Coronal CT images

Coronal CT images (a-f) showing a twisted vascular pedicle (arrow) entering a hypodense,
 slightly heterogeneous structure. (*) Note fat stranding (arrowhead) secondary to
inflammatory changes and small volume ascites (open arrow)
© Simões, A, Department of Radiology, Centro Hospitalar São João, Porto, Portugal.

Area of Interest: Paediatric;

Imaging Technique: CT;
Procedure: Diagnostic procedure;
Special Focus: Ischaemia / Infarction;

Figure 2 Axial CT Images

Axial CT Images (a - d) showing showing a twisted vascular pedicle (arrow) entering a

hypodense, slightly heterogeneous structure (*). Note fat stranding (arrowhead) secondary to
inflammatory changes and small volume ascites (open arrow).
© Simões, A, Department of Radiology, Centro Hospitalar São João, Porto, Portugal.

Area of Interest: Paediatric;

Imaging Technique: CT;
Procedure: Diagnostic procedure;
Special Focus: Ischaemia / Infarction;

Figure 3 Axial and coronal CT images

Axial (a) and coronal (b) CT images showing the absence of spleen in its usual position.
 Note fat stranding (arrowhead) secondary to inflammatory changes and small volume ascites
(open arrow).
© Simões, A, Department of Radiology, Centro Hospitalar São João, Porto, Portugal.

Area of Interest: Paediatric;

Imaging Technique: CT;
Procedure: Diagnostic procedure;
Special Focus: Ischaemia / Infarction;

References
[1] Murthy, M. et al. (2008) Splenic torsion, an unusual cause of acute abdominal pain The Internet
Journal of Radiology Volume 10 Number 2

[2] Fiquet-Francois, C. et al. (2010) Wandering spleen in children: multicenter retrospective study
Journal of Pediatric Surgery 45: 1519-1524

[3] Arleo, E. K. et al. (2010) Multimodality imaging of a neonatal wandering spleen Clinical
Imaging 34: 302-305

[4] DeJohn, L. et al. (2008) Wandering spleen: A rare diagnosis with variable presentation
Radiology Case Reports 3: 229

[5] Brown, C. V. R. et al. (2003) Wandering spleen and its complications in children: A case series
and review of literature Journal of Pediatric Surgery 38 (11): 1676-1679

[6] Liu, H. M. et al. (2007) Wandering spleen: An unusual association with gastric volvulus
American Journal of Radiology 188: w328-w330

[7] Palanivelu, C. M. S. et al. (2007) Laparoscopic Mesh Splenopexy (Sandwich Technique) for
Wandering Spleen Journal of the Society of Laparoendoscopic Surgeons 11(2):246-51

Citation
Simões, André; Lopes, Pedro; Viamonte, Bárbara. (2014, Sep. 16)
Wandering Spleen {Online}
URL: http://www.eurorad.org/case.php?id=12042