Torsion of a Wandering Spleen With Splenic and Gastric Varices Presenting as Abdominal Pain

Abstract

A wandering or ectopic spleen (splenoptosis) is extremely rare with a reported incidence of less than 0.2%. It only accounts for less than 0.25% of patients undergoing splenectomies. It is an elusive clinical diagnosis due to the variable presentation ranging from an abdominal mass to abdominal pain. This is a case of a 29 year old female with acute abdominal pain from torsion of a wandering spleen. A 29 year old female with history of gastroesophageal reflux disease presented to the emergency room with a 3 day history of worsening abdominal pain and a sensation of an abdominal mass in the left upper quadrant. On evaluation, she was afebrile and hemodynamically stable, with splenomegaly greater than 10 cm below the left costal margin and left upper quadrant tenderness. The rest of the exam was unremarkable. The platelet count was 115 x 109/L. Computerized tomography showed torsion of an enlarged spleen measuring 15cm that was displaced inferiorly with abundant splenic and gastric varices. Laparoscopic splenectomy was done on the third hospital day. Intraoperatively, the spleen was found in the pelvis with a 720 degree counter clockwise torsion around the pedicle. The post-operative course was uneventful. A wandering spleen refers to its presence in a location other than the left upper quadrant. It may be due to the absence or underdevelopment of splenic supportive ligaments, or from abdominal wall laxity or hormonal effects. It is predisposed to torsion due its long pedicle. Some are asymptomatic, while others present with abdominal pain from torsion or splenomegaly from vascular congestion. Persistent torsion of more than 180 degrees can lead to splenic infarction. The index patient had chronic volvulus of the spleen given the presence of splenic and gastric varices. Imaging modalities are crucial because early clinical diagnosis is difficult. Splenectomy is recommended if there is infarction, vessel thrombosis, functional asplenia or hypersplenism. However, splenopexy is preferred if there is a viable wandering spleen to avoid post-splenectomy sepsis. In conclusion, timely diagnosis is important to avoid life threatening complications such as splenic infarction or gastric variceal bleeding. This case highlights the crucial role of imaging in the prompt diagnosis and treatment of this rare condition.