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Acute Torsion of Wandering Spleen: MRI Findings

Hôpital Tenon Paris 75020, France

Wandering spleen is a rare disorder in which the spleen is not located in the left upper quadrant but is found lower in the abdomen or in the pelvic region. To our knowledge, we report the first case of complicated wandering spleen that was diagnosed preoperatively on MRI.

A 29-year-old woman with acute right lower abdominal pain and vomiting was referred by her general practitioner. Physical examination revealed a large tender mass in the right lower quadrant. She had mild thrombocytopenia (66 x 10³/µL), but the WBC and hemoglobin concentrations were normal. Sonographic examination showed a homogeneous 15 x 8 x 6 cm mass with echogenicity that was consistent with normal spleen tissue, and the normal splenic bed in the left upper abdomen was empty. MRI showed an enlarged heterogeneous pelvic spleen; lack of enhancement of the upper part was suggestive of infarction (Fig. 5A). Gadolinium-enhanced MR angiography identified a long ectopic splenic artery extending toward the splenic mass. The tail of the pancreas was located next to the ectopic pedicle (Fig. 5B). Emergency laparotomy confirmed the presence of a large pelvic spleen twisted out of 360° on its long pedicle, with partial infarction of the upper region. No suspensory ligaments were found, and the spleen was therefore removed. Histopathologic examination confirmed the partial infarction (Fig. 5C) and showed an aneurysm of the splenic artery. The postoperative course was uneventful.

View larger version (115K): [in this window] [in a new window] [as a PowerPoint slide]   Fig. 5A. —29-year-old woman with complicated wandering spleen. Sagittal T1-weighted MR image (TR/TE, 500/30) with gadolinium enhancement shows enlarged pelvic spleen. Note heterogeneous enhancement in upper region (arrow), suggesting infarction.

View larger version (81K): [in this window] [in a new window] [as a PowerPoint slide]   Fig. 5B. —29-year-old woman with complicated wandering spleen. Arterial phase MR angiogram with 3D maximum-intensity-projection reconstruction shows elongated ectopic pedicle (single arrow) extending toward pelvic spleen (arrowhead). Note tail of pancreas next to splenic artery (double arrow).

View larger version (120K): [in this window] [in a new window] [as a PowerPoint slide]   Fig. 5C. —29-year-old woman with complicated wandering spleen. Photograph of resected specimen shows congested excised spleen. Note infarction of upper part (arrow) and aneurysm of distal portion of splenic artery (arrowhead).

Wandering spleen is found in fewer than 0.5% of splenectomies [1]. Wandering spleen may remain asymptomatic or cause chronic abdominal discomfort due to intermittent self-resolving torsion. Torsion of the vascular pedicle can hinder venous outflow, with a risk of congestion, stasis, and life-threatening complications such as splenic gangrene or abscess and hemorrhage. The principal therapeutic options for wandering spleen are splenopexy and splenectomy [2]. Spleen-preserving treatment should be attempted if signs of infarction or necrosis are absent.

Sonography can show an ectopic comma-shaped spleen and the absence of splenic tissue in the upper left quadrant but may fail to detect the heterogeneous aspect of an infarcted spleen [3]. Unenhanced CT can show a decrease in spleen attenuation, and contrast medium administration may show a partial or total lack of enhancement [4]. MRI, a reasonable alternative to CT, confirmed the diagnosis of a complicated wandering spleen. The lack of splenic tissue in the upper left quadrant and the ectopic pelvic spleen were easily detected on T1- and T2-weighted sequences. The viability of the splenic parenchyma was assessed by T1-weighted MRI (with and without contrast medium administration) and showed a partial infarction. This information is useful for therapeutic decision-making [1]. In addition, MR angiography is useful for obtaining information on the location and length of the splenic artery before surgery. The distal splenic artery aneurysm revealed at pathology was not retrospectively visualized on the MR angiography.

MRI can thus provide useful information on the precise location of the wandering spleen, the viability of the splenic parenchyma, and the splenic vessel anatomy.

References

1. Sayeed S, Koniaris LG, Kovach SJ, Hirokawa T. Torsion of a wandering spleen. Surgery2002; 132:535 –536[Medline]
2. Peitgen K, Majetschak M, Walz M. Laparoscopic splenopexy by peritoneal and omental pouch construction for intermittent splenic torsion ("wandering spleen"). Surg Endosc2001; 15:413
3. Nemcek AA Jr, Miller FH, Fitzgerald SW. Acute torsion of a wandering spleen: diagnosis by CT and duplex Doppler and color flow sonography. AJR1991; 157:307 –309[Free Full Text]
4. Raissaki M, Prassopoulos P, Daskalogiannaki M, Magkanas E, Gourtsoyiannis N. Acute abdomen due to torsion of wandering spleen: CT diagnosis. Eur Radiol1998; 8:1409 –1412[Medline]

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This Article Figures Only Full Text (PDF) Alert me when this article is cited Alert me if a correction is posted Services Email this article to a friend Similar articles in this journal Similar articles in PubMed Alert me to new issues of the journal Download to citation manager Citing Articles Citing Articles via Google Scholar Google Scholar Articles by Deux, J.-F. Articles by Bazot, M. Search for Related Content PubMed PubMed Citation Articles by Deux, J.-F. Articles by Bazot, M. Social Bookmarking                      What's this?