Wandering spleens are rare clinical entities found more commonly in females.
We report a young female patient found to harbour a pelvic spleen. The literature
regarding this rare ectopia is reviewed. The wandering spleen should be
considered in the differential diagnosis of pelvic masses

Jamali, F.

Khaki, A.A.

Salavati, A.

Tanoomand, A.

Tubbs, R.S.

Zarrintan, S.

English

Via Medica Journals

Folia Morphol. Vol. 66, No. 2, pp. 152–154Copyright © 2007 Via MedicaISSN 0015–5659www.fm.viamedica.plC A S E   R E P O R T152Address for correspondence: R.S. Tubbs, PhD, Paediatric Neurosurgery, Children’s Hospital, 1600 7th Avenue South ACC 400, Birmingham,Alabama 35233, USA, tel: 205 939 9914, fax: 205 939 9972, e-mail: rstubbs@uab.eduA wandering spleen presenting as a pelvicmass: case report and review of the literatureS. Zarrintan1, F. Jamali2, 3, R.S. Tubbs4, A.A. Khaki5, A. Salavati6, A. Tanoomand71Student Research Centre and Faculty of Medicine, Tabriz University of Medical Sciences, Tabriz, Iran2Maragheh Amiralmomenin Hospital, Maragheh, Eastern Azerbaijan, Iran3Maragheh Islamic Azad University, Maragheh, Eastern Azerbaijan, Iran4Section of Pediatric Neurosurgery, University of Alabama at Birmingham and Children’s Hospital, Birmingham,Alabama, USA5Department of Anatomical Sciences, Faculty of Medicine, Tabriz University of Medical Sciences, Tabriz, Iran6Students’ Scientific Research Centre and Faculty of Medicine, Tehran University of Medical Sciences, Tehran, Iran7Maragheh Faculty of Nursery and Midwifery, Tabriz University of Medical Sciences, Eastern Azerbaijan, Iran[Received 23 November 2006; Revised 1 March 2007; Accepted 1 March 2007]Wandering spleens are rare clinical entities found more commonly in females.We report a young female patient found to harbour a pelvic spleen. The litera-ture regarding this rare ectopia is reviewed. The wandering spleen should beconsidered in the differential diagnosis of pelvic masses.Key words: spleen, pelvis, ectopicINTRODUCTIONLack of fixation of the spleen in its normal posi-tion in the left upper quadrant of the abdomen mayresult in splenic mobility. This uncommon conditionis referred to as a “wandering spleen” [1, 5, 9]. It ispostulated that major supporting ligaments of thespleen are abnormally lax or elongated in patientswith a wandering spleen, allowing the organ to mi-grate to the lower abdomen or, rarely, the pelvis[1, 5, 11, 12]. The incidence of wandering spleen is15 times greater in women than in men, especiallyin women aged 20–40 [9], which may be due to thehormonal effects of pregnancy [1].CASE REPORTA 20-year-old nulliparous woman presented withperiumbilical pain one day prior to admission. Thepain was followed approximately 5 hours later bypain in her right lower quadrant, which was exacer-bated with movement. She also complained of an-orexia. During physical examination the surgeonobserved mild tenderness and rebound tendernessin the right lower quadrant. With leukocytosis, rightlower quadrant pain and fever, the patient was pre-pared for appendectomy. Sonographic examinationsfailed to locate the spleen in its normal position, andan abnormal low-echoic homogeneous soft-tissuemass was detected in the left side of the pelvis (Fig. 1).In computed tomography imaging the unknownmass had characteristics consistent with the spleen(Fig. 2). Doppler imaging showed normal blood flowin the suspected ectopic splenic vessels and the pa-tient therefore underwent surgery for acute appen-dicitis and correction of a pelvic spleen. The primarydiagnosis of acute appendicitis was confirmed bypathology studies. A splenopexy was performed. Fourmonths after the treatment ultrasonography wasperformed and revealed a normally located spleen.DISCUSSIONWandering spleens, also referred to as “ectopic”,“proptotic”, “floating”, “displaced” and “aberrant”spleens are rare clinical entities [1, 5, 9, 11, 12]. Mosttextbooks do not consider this in the differentialdiagnosis of pelvic masses. The spleen begins de-velopment in the fifth week of gestation from153S. Zarrintan et. al., An ectopic spleen in the pelvismesenchymal cells in the dorsal mesogastrium [12].The dorsal mesogastrium is also responsible for theformation of the peritoneum, the greater omentumand several peritoneal folds [1]. The major support-ing ligaments of the spleen are the gastrosplenic,phrenocolic, splenorenal, and splenocolic liga-ments. Potential aetiologies for a wandering spleeninclude a congenital abnormality of its peritonealattachments or an acquired laxity of these liga-ments [1, 12].Although rare, a wandering spleen is more oftenseen in young multiparous women [9]. Potentiallypredisposing elements in this population includemultiparity and abdominal laxity [5, 12], thought tobe secondary to pregnancy-induced hormonal effectson the abdominal wall. In addition, splenomegalymay predispose one to a proptotic spleen [12]. Theclinical presentation of a wandering spleen is vari-able. It may be manifest clinically as an abdominalmass or abdominal pain. Abdominal pain will beexperienced by 60% of patients, and the remainderwill be asymptomatic [9]. If pain is present, it maybe chronic, intermittent or acute [9, 12]. Prompt di-agnosis is necessary to prevent complications suchas splenic torsion with resultant splenic infarction [10],gastric volvulus [13] or acute pancreatitis [6].On physical examination there may be a hard ovoidpalpable pelvic mass with a notched edge. The massmay move painlessly toward the left upper quad-rant, but movements in other directions may be lim-ited or painful. There will also be resonance to per-cussion in the left upper quadrant. The wanderingspleen may be normal in size or enlarged [1].Whereas in the past most cases were diagnosedduring exploratory laparotomy [4], the diagnosis isnow usually established by means of imaging [4, 11].Abdominal sonography [11] is currently the firstmode of evaluation for abdominal pain or masses.As ultrasonography can easily be repeated and, as itportrays the shape and position of the spleen ona real-time basis, the preoperative diagnosis of a wan-dering spleen is possible. With advances in ultrasono-graphic technology, such as colour Doppler imag-ing and power Doppler imaging, the occurrence oftorsion or infarction of the spleen can easily be con-firmed. Ultrasonography is therefore a simple anduseful method for diagnosing a wandering spleen inpatients who complain of intermittent left hypochon-dralgia, especially in women following childbirth [16].Because the imaging characteristics may differ frompatient to patient, it is important to have accurateinformation about this entity in order to make a con-clusive and correct diagnosis [8]. Computed tomog-raphy scans or magnetic resonanse imaging are alsooccasionally used. These imaging studies may showan abdominal or pelvic mass, loops of intestine inFigure 2. Computed tomography of the pelvis noting the abnor-mally positioned spleen (arrow) within the pelvis.Figure 1. Ultrasound of the wandering spleen as seen in our pa-tient. LK — left kidney; SP — spleen.154Folia Morphol., 2007, Vol. 66, No. 2the left upper quadrant instead of the normally lo-cated spleen, an elevated left kidney or gastrointes-tinal obstruction [5, 9]. Laboratory evidence of leu-kocytosis, platelet abnormalities and anaemia maybe present but are not necessary or diagnostic [9].Pancreatitis may also result from incorporation ofthe tail of the pancreas into the spleen’s vascularpedicle [3]. Diagnosis, however, may be difficult be-fore surgical management. In a review of 237 casespublished in 1992 only 27% were diagnosed preop-eratively [1]. However, with advances in ultrasonog-raphy techniques, the preoperative diagnosis ofa wandering spleen has become more common [8,11, 15, 16].Treatment options include observation, sple-nectomy or splenopexy. In children observation isoften the initial recommended treatment. Becauseof the high risk of complications and the increasedrisk of trauma to an unprotected abnormally lo-cated spleen, wandering spleen is treated surgi-cally by either splenopexy or splenectomy in allpatients, even those who are asymptomatic [2, 7].Its clinical appearance assumes various forms, withthe most common complication being torsion ofthe spleen. Because this acute torsion often caus-es infarction of the spleen, splenectomy may beinevitable [14]. If the diagnosis is made before se-vere complications occur, elective laparoscopicsplenopexy is now considered the treatment ofchoice. Post-splenectomy septicaemia is one of themajor risks of removing the spleen. Patients whohave undergone splenectomy are at increased riskof infection, especially with encapsulated organ-isms, such as Streptococcus pneumoniae, Neisseriameningitidis and Haemophilus influenzae. Second-ary to complications related to splenectomy, therehas been a greater trend toward more conservativesurgical management with splenopexy [7]. Sple-nopexy can be performed with various techniques,including the creation of an extraperitoneal pocket,colonic displacement, suture fixation or reinforce-ment pockets made of mesh or omentum [7].In conclusion, wandering spleen is a rare entitybut must be considered in patients with an abdom-inal or pelvic mass. The clinical presentation rangesfrom asymptomatic to an acute surgical abdomen.Diagnosis, if made preoperatively, can usually bereached by ultrasound with or without Doppler studies.Treatment options include observation, splenecto-my, and splenopexy. The risks and benefits of thesetreatments must each be considered and tailored tothe individual patient.REFERENCES1. Allen KB, Gay BB, Skandalakis JE (1992) Wanderingspleen: anatomic and radiologic considerations. SouthMed J, 85: 976.2. Benevento A, Boni L, Dionigi G (2002) Emergency lap-aroscopic splenectomy for “wandering” (pelvic) spleen:case report and review of the literature on laparoscopicapproach to splenic diseases. Surg Endosc, 16: 1364––1365.3. Benoist S, Imbaud P, Veyrieres M (1998) Reversible hy-persplenism after splenopexy for wandering spleen.Hepatogastroenterology, 45: 2430–2431.4. Brown CV, Virgilio GR, Vazquez WD (2003) Wander-ing spleen and its complications in children: a caseseries and review of the literature. J Pediatr Surg, 38:1676.5. Buehner M, Baker MS (1992) The wandering spleen.Surg Gynecol Obstet, 175: 373.6. Choi YH, Menken FA, Jacobson IM (1996) Recurrentacute pancreatitis: an additional manifestation of the‘‘wandering spleen’’ syndrome. Am J Gastroenterol,91: 1034.7. Cohen MS, Soper NF, Underwood RA, Quasebarth M,Brunt LM (1998) Laparoscopic splenopexy for wander-ing (pelvic) spleen. Surg Laparosc Endosc, 8: 286–290.8. Danaci M, Belet U, Yalin T, Polat V, Nurol S, Selcuk MB(2000) Power Doppler sonographic diagnosis of tor-sion in a wandering spleen. J Clin Ultrasound, 28: 246.9. Desai DC, Hebra A, Davidoff AM (1997) Wanderingspleen: a challenging diagnosis. South Med J, 90: 439.10. Greig JD, Sweet EM, Drainer IK (1994) Splenic torsionin a wandering spleen presenting as an acute abdom-inal mass. J Pediatr Surg, 29: 571.11. Karmazyn B, Steinberg R, Gayer G (2005) Wanderingspleen — the challenge of ultrasound diagnosis: re-port of 7 cases. J Clin Ultrasound, 33: 433–438.12. Lewis GA, Byrne MP (1981) Wandering spleen. AmSurg, 47: 275–277.13. Lin CH, Wu SF, Lin WC (2005) Wandering spleen withtorsion and gastric volvulus. J Formos Med Assoc, 104:755–758.14. Nemcek AA, Miller FH, Fitzgerald SW (1991) Acute tor-sion of a wandering spleen: diagnosis by CT and du-plex Doppler and color flow sonography. Am J Roent-genol, 157: 307–309.15. Satyadas T, Nasir N, Bradpiece HA (2002) Wanderingspleen: case report and literature review. J R Coll SurgEdinb, 47: 512–514.16. Wen YL, Kudo M, Maekawa K (2001) Sonographic find-ings of wandering spleen. J Gastroenterol, 36: 643––644.

A wandering spleen presenting as a pelvic mass: case report and review of the literature

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A wandering spleen presenting as a pelvic mass: case report and review of the literature

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