British Journal of Radiology (2005) 78, 1050-1052
© 2005 British Institute of Radiology
doi: 10.1259/bjr/33073529
Pseudocyst formation: a rare complication of wandering spleen
K Taori, MD,
R Sanyal, MBBS,
A Deshmukh, DMRD and
T Saini, MBBS
Department of Radiology, Government Medical College, Nagpur, PIN 440003, India
 |
Abstract
|
|---|
Wandering spleen is a rare entity, in which the spleen is abnormally mobile due to its attachment by a long vascular pedicle. This long vascular pedicle predisposes it to various complications, the most common being torsion. Here, we present a case in which a wandering spleen in a young female was complicated by pseudocyst formation, and discuss the possible aetiology, pathogenesis, diagnosis and therapeutic implications of this extremely rare complication.
|
Introduction
|
|---|
Wandering or ectopic spleen is a rare entity, in which the spleen is attached by a long, vascular pedicle and migrates from its normally fixed location in the left upper quadrant. The mobility of the spleen due to its abnormally long vascular pedicle predisposes it to various complications such as torsion, infarction, gangrene, abscess formation, variceal haemorrhage and pancreatic necrosis [1–3]. Here, we present a case in which a wandering spleen in a young female was complicated by pseudocyst formation, and discuss the possible aetiology, pathogenesis, diagnosis and therapeutic implications of this extremely rare complication.
|
Case report
|
|---|
A 20-year-old, nulliparous female presented with complaints of intermittent abdominal pain. On physical examination, a large mobile lump was palpated in the pelvis. The rest of the physical examination and routine laboratory tests were unremarkable. Plain radiograph of the abdomen revealed bowel loops occupying the left upper quadrant with a large soft tissue shadow in the hypogastrium (Figure 1
). On ultrasound examination, the soft tissue shadow was identified as an abnormally positioned spleen with a well-defined, 10 cm x 5 cm cystic lesion with diffuse low level internal echoes and through transmission, in its lower pole (Figure 2). Contrast-enhanced (CE) CT examination in the supine position revealed the stomach occupying the splenic fossa, and the spleen located in pelvis on the left side, mimicking a space occupying lesion. There was a non-enhancing cystic lesion with imperceptible walls in the spleen. The rest of the spleen showed normal enhancement pattern (Figure 3). On both Doppler and CECT examinations, splenic vessels showed normal flow. On scanning in right decubitus position during ultrasound and CT examinations (Figure 4), the spleen, along with the cyst, migrated to the dependent position on the right side. This prompted a diagnosis of wandering spleen containing a benign cystic lesion. On exploratory laparotomy, the spleen was found to be freely mobile in the peritoneal cavity. A decision was made to perform splenectomy as it was not possible to rule out an infected parasitic cyst intraoperatively. On histopathology a pseudocyst of the spleen, possibly infected, was reported.
View larger version (111K):
[in this window]
[in a new window]
|
Figure 1. Abdominal radiograph revealed bowel loops occupying the left upper quadrant with a large soft tissue shadow in the hypogastrium.
|
|
View larger version (93K):
[in this window]
[in a new window]
|
Figure 2. Ultrasound shows abnormally placed spleen with large well-defined cystic lesion with internal echoes.
|
|
View larger version (93K):
[in this window]
[in a new window]
|
Figure 4. CT in supine position, more distal section, reveals the ectopic spleen with a large cyst within it, located in pelvis.
|
|
|
Discussion
|
|---|
The migration of the spleen from its anatomical position is caused by the absence or abnormal laxity of splenic attachments, due to either acquired or congenital causes. The abnormally long and mobile vascular pedicle predisposes the wandering spleen to a number of complications with torsion being the most serious [4].
Acute torsion presents as acute abdomen and causes vascular congestion, infarction, and even gangrene. This is related to the speed and degree of torsion. Chronic intermittent torsion causes venous congestion and splenomegaly and presents with intermittent abdominal pain [5]. Other complications of wandering spleen which have been described are acute pancreatic necrosis due to the incorporation of the tail of the pancreas in the spleen's vascular pedicle, splenic abscess formation, gastric distention and variceal haemorrhage [1–3].
In our patient, a large pseudocyst was present in the spleen, which is a very rare complication. In our review of literature, we could find only one previously reported case of a traumatic pseudocyst in a wandering spleen [6]. Splenic cysts are quite rare, and can be classified into parasitic and non-parasitic [7]. Of the non-parasitic cysts, true cysts having an epithelial lining constitute about 20%, while the rest comprise of pseudocysts. The wall of a pseudocyst is composed of dense fibrous tissue with no epithelial lining and occasionally contains haemosiderin. In our case, focal aggregates of inflammatory cells were identified in the wall, suggesting the possibility of an infected pseudocyst. However, no organism was identified by culture or staining. Pseudocysts of the spleen are caused by either trauma [8] or infarction. Our patient complained of intermittent abdominal pain, but denied any history of trauma. However, an enlarged ectopic spleen could be vulnerable to injury due to trivial unnoticed trauma. Another possible aetiology could be intermittent episodes of torsion, resulting in embolic/thrombotic episodes, leading to infarction and subsequent pseudocyst formation.
A wandering spleen is rare anomaly with a reported incidence in several large series of splenectomies of less than 0.5%. It can be asymptomatic, present as acute abdomen, or as intermittent abdominal pain. 60% of patients present with painful abdominal mass [5]. This varied clinical presentation necessitates radiological evaluation for confirmation of the diagnosis. Ultrasound as well as CT are modalities which can be used to locate the ectopic spleen, as well as demonstrate its vascularity and viability. The key is to perform the examination in different positions to demonstrate the mobility of the spleen.
Splenoplexy has now been established as the treatment of choice in patients with wandering spleen to prevent any future complications [9, 10]. In the absence of infarction it has replaced splenectomy, particularly in children, in whom preservation of splenic tissue is of vital importance. In our patient, although the splenic tissue was viable, the presence of a large cyst, which possibly could have been a parasitic cyst, prompted splenectomy.
To conclude, the vulnerability of a wandering spleen predisposes it to various complications, of which pseudocyst formation is a very rare one, but deserves special mention because of its diagnostic and therapeutic implications.
Received for publication January 7, 2005.
Revision received February 17, 2005.
Accepted for publication April 26, 2005.
|
References
|
|---|
- Shiels WE, Johnson JF, Stephenson SR, et al. Chronic torsion of the wandering spleen. Pediatr Radiol 1989;19:465–7.[CrossRef][Medline]
- Parker LA, Mittlestaedt CA, Mauro MA, et al. Torsion of the wandering spleen: CT appearance. J Comput Assist Tomogr 1984;8:1201–4.[Medline]
- Sheflin JJ, Lee CM, Kretchmar K. Torsion of wandering spleen and distal pancreas. Am J Radiol 1984;142:100.[Free Full Text]
- Abell I. Wandering spleen with torsion of the pedicle. Ann Surg 1993;98:722–35.
- Desai DC, Hebra A, Davidoff AM, et al. Wandering spleen: a challenging diagnosis. South Med J 1997;90:439–43.[Medline]
- Dowidar M. Wandering spleen: report of a case complicated by a traumatic cyst. Ann Surg 1949;129:408–14.[Medline]
- Eisental TC, Monis PM, Masan RG. Cysts of the spleen. Am J Surg 1977;134:635–7.[CrossRef][Medline]
- Topilow AA, Steinhoft NG. Splenic pseudocysts, a late complication of trauma. J Trauma 1975;15:260–3.[Medline]
- Jones BJ, Daley M, Delaney PV. Torsion of spleen managed by splenoplexy. Br J Surg 1991;78:887–8.[Medline]
- Seashore JH, McIntosh S. Elective splenoplexy for wandering spleen. J Pediatr Surg 1990;25:270–2.[CrossRef][Medline]
Top
Abstract
Introduction
