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Case Report |
1 Department of Radiology, Monash Medical Center, Rm. 116, 246 Clayton Rd.,
Clayton South, Victoria 3168, Australia.
2 Present address: Department of Radiology, The Canberra Hospital, Yamba Dr.,
Garran, ACT 2065, Australia.
Received April 19, 2005;
accepted after revision June 17, 2005.
Address correspondence to H.-T. M. Liu
(htliu2003{at}yahoo.com.au).
Keywords: abdomen • abdominal imaging • anatomy • pediatric radiology • spleen
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Abdominal radiography was unremarkable, showing no dilatation of bowel loops. A barium meal examination was performed because of the clinical suspicion of malrotation. It showed a left-sided congenital diaphragmatic hernia and an intrathoracic gastric volvulus (Fig. 1A). Sonography revealed a medial displacement of the spleen immediately inferior to the right lobe of liver (Fig. 1B). Subsequent CT showed the intrathoracic position of the left kidney and stomach and a gastric volvulus in the mesoaxial direction (along the line joining the greater and lesser curvature) (Fig. 1C). It also confirmed the displacement of the spleen to the right side of the abdomen (Fig. 1D).
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Wandering spleen is by definition a mobile spleen that is attached only by an elongated vascular pedicle, allowing it to migrate to any part of the abdomen or pelvis. It is a rare congenital malformation resulting from abnormal development of the splenic peritoneal attachments [5, 6]. Most cases in children occur when the child is younger than 1 year; the male-to-female ratio is 6:1 [7, 8]. During fetal development, the dorsal mesogastrium fails to fuse with the posterior peritoneum, leading to a laxity or absence of formation of splenic supporting ligaments [5, 6]. These ligaments include the pancreaticocolic, splenocolic, gastrosplenic, pancreaticosplenic, phrenicocolic, splenorenal, and phrenicosplenic ligaments. For this reason, the splenic pedicle has an increased risk of axial torsion that can lead to splenic congestion and ultimately to splenic infarction [7, 8].
The condition also can occur in adults at 20-40 years because of laxity of the ligamentous support as a result of splenomegaly or pregnancy [9]. Fifteen percent of children with wandering spleen are asymptomatic, whereas 55% present with abdominal pain and 90% present with a palpable mass outside the left upper quadrant [10]. Torsion complicates 64% of pediatric wandering spleens [11]. Splenic torsion is usually clockwise and can cause vascular congestion, infarction, and even gangrene of the spleen [12, 13].
Several imaging studies may be helpful in establishing the diagnosis of wandering spleen, and debate still exists concerning which test is most appropriate. Abdominal radiography may reveal the absence of a splenic silhouette [4]. Abdominal sonography is useful in establishing the absence or presence of a spleen in the left upper quadrant, but it may be obscured by bowel gas [13]. Also, a duplex study can be performed to assess splenic blood flow and is useful in establishing whether splenic torsion is present [13]. CT shows an abnormal location of the spleen or abnormality of surrounding viscera, such as gastric malposition or volvulus [1, 2, 5]. Other findings include necrosis and involvement of the pancreatic tail and surrounding fat due to torsed splenic vessels [2-4].
Splenopexy is the procedure of choice to prevent future torsion while preserving functional splenic tissue when a viable wandering spleen is found at surgery [10-12].
There is a rare association between gastric volvulus and wandering spleen [2, 5]. The two entities share a common cause, the absence or laxity of intraperitoneal visceral ligaments. Prophylactic gastropexy in patients with wandering spleen may therefore be implicated [5].
Our patient also had a coincidental left diaphragmatic hernia.
In conclusion, it is important to recognize a wandering spleen because of the configuration of its vascular pedicle, which makes it prone to splenic torsion. Wandering spleen has a rare association with gastric volvulus. Both splenic torsion and gastric volvulus are potentially life-threatening if not immediately managed surgically.
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  R. K. Cribbs, K. W. Gow, and M. L. Wulkan Gastric Volvulus in Infants and Children Pediatrics, September 1, 2008; 122(3): e752 - e762. [Abstract] [Full Text] [PDF]
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