|Year : 2015 | Volume
| Issue : 2 | Page : 37-40
Wandering spleen causing recurrent abdominal pain
Jude N Nwashilli, McGee O Ezeokenwa, John K Ukwuoma
Department of Surgery, University of Benin Teaching Hospital, Benin City, Edo State, Nigeria
|Date of Web Publication||19-May-2016|
Jude N Nwashilli
Department of Surgery, University of Benin Teaching Hospital, Benin City, Edo State
Source of Support: None, Conflict of Interest: None
Wandering spleen is a rare condition that accounts for < 0.25% of all indications for splenectomy. It is characterized by ectopic localization of the spleen owing to the lack or weakening of its ligaments. Clinical presentation is varied and ranges from asymptomatic abdominal mass to an abdominal mass with recurrent pain and acute abdomen following torsion of its pedicle. We report a case of wandering spleen in a 47-year-old female presenting with recurrent abdominal pain for a year duration, which was treated by splenectomy.
Keywords: Abdominal mass, recurrent abdominal pain, wandering spleen
|How to cite this article:|
Nwashilli JN, Ezeokenwa MO, Ukwuoma JK. Wandering spleen causing recurrent abdominal pain. Niger J Surg Sci 2015;25:37-40
| Introduction|| |
Wandering spleen is a rare condition which may be incidentally detected as an abdominal mass or it can present with torsion of its pedicle causing an acute abdomen. Synonyms used to describe it are displaced spleen, drifting spleen, ectopic spleen, floating spleen, splenic ptosis, splenoptosis, systopic spleen, or pelvic spleen. It is characterized by the absence or underdevelopment of one or all ligaments that hold the spleen in its normal anatomical position in the left upper quadrant of the abdomen.  The abnormally fixed spleen can twist on its pedicle leading to ischemia, which may progress to infarction. It affects mainly children (one-third of cases), with a female predominance after age one.  In adults, women of reproductive age are most frequently affected, due to acquired laxity of the splenic ligaments. 
The clinical presentation of wandering spleen is nonspecific. It may present as an asymptomatic mass, a mass with recurrent abdominal pain resulting from torsion and de-torsion of the splenic pedicle, or as an acute abdomen following torsion of its pedicle with vascular compromise. Abdominal ultrasound or computed tomography scan is required to make diagnosis; treatment is either splenopexy or splenectomy.
Although there are a good number of publications on the subject, few cases have been reported in our environment. Recent reported cases of such clinical condition in our environment were by Ugwu et al.  in South-East Nigeria and Tabowei and Kombo  in South-South Nigeria.
We present a case of wandering spleen in a 47-year-old female presenting with recurrent abdominal pain, which was treated by splenectomy.
| Case report|| |
A 47-year-old female, Parity five, presented with a recurrent 1-year history of left-sided abdominal swelling. The swelling progressively increased in size extending from the left upper abdomen to below the umbilicus. There was associated recurrent, sharp pain in the upper abdomen and over the swelling, transiently relieved by analgesics. There was no history of abdominal trauma, chronic cough, chest pain, night sweats, or weight loss. She had no fever, anorexia, early satiety, yellowness of the eyes, or bone pains. A review of other systems was normal.
Physical examination revealed an obese woman (body mass index = 39), pale, afebrile, anicteric, and not dehydrated, with neither pedal edema nor peripheral lymphadenopathy. Her pulse rate was 84/min, blood pressure 130/90 mmHg, and respiratory rate 22 c/min. Abdomen was distended and moved with respiration. A large, firm, tender mass was palpable extending from the left costal margin and epigastrium down to below umbilicus and left lumbar region [Figure 1]. Swelling moves with respiration with a palpable medial notch. One can get below it but not above it. There was associated hepatomegaly with a liver span of 20 cm. There was no ascites, and digital rectal examination was normal. The examination of the remainder systems was normal.
Complete blood count revealed a low hematocrit of 28% (Hb = 9.8 g/dl) and normal total white blood cell count and platelet with neutrophilia (86%). Erythrocyte sedimentation ratio was elevated (106 mm/hour). Electrolytes, urea and creatinine, random blood sugar, and urinalysis were normal. An abdominal computed tomography scan showed a markedly enlarged spleen with multiseptae cystic mass within it measuring 16 cm × 17.5 cm × 16.3 cm in size displacing the left kidney downward and stomach and pancreas medially [Figure 2] and [Figure 3]. Other organs were normal. A chest radiograph, echocardiography, and electrocardiogram were normal.
|Figure 2: Abdominal computed tomography scan showing the enlarged spleen in the patient|
Click here to view
|Figure 3: Abdominal computed tomography scan showing multiseptae mass (enlarged spleen) in the patient|
Click here to view
At operation, a large cystic spleen filled with blood with a long pedicle extending from the costal margin to below the umbilicus was noted [Figure 4]. Splenectomy was carried out, and the spleen weighed 3700 g; the normal weight of adult spleen is 150-200 g. The liver was enlarged with smooth surface. Other organs were normal. Postoperative period was uneventful, and she was vaccinated against Streptococcus pneumoniae, Neisseria More Details meningitidis, and Haemophilus influenzae. She was discharged on the 10 th day postoperative. Histology showed congested spleen filled with blood without evidence of malignancy.
| Discussion|| |
Wandering spleen is very rare, with fewer than 500 occurrences of the condition reported as of 2005.  It is most commonly diagnosed in young children,  as well as women between the ages of 20 and 40.  The case reported occurred in a middle-aged female.
The possible etiological factors in this patient may be congenital or acquired. The splenic ligaments fix the spleen in its anatomical position. When it is congenitally malformed, it leads to ligamentous laxity and weakening. Stretching of the ligaments by enlarged spleen will lead to its displacement from its anatomical position. Multiparity can increase abdominal wall laxity, thereby reducing abdominal wall muscle tone which normally supports intra-abdominal organs in their anatomical position. This may be the probable etiology in this reported case as the patient is grand multiparous. Splenomegaly from parasitic infections (malaria and hydatid disease), tumors, and posttraumatic injury of the spleen may stretch the splenic ligaments leading to its displacement from its normal position. However, none of these causes of splenomegaly were established in this reported case.
The symptoms of wandering spleen may vary from an asymptomatic intra-abdominal mass to acute abdominal signs resulting from splenic torsion. Patients may have recurrent or intermittent abdominal pain resulting from torsion and de-torsion, which is similar to the case presented, as the patient had been having recurrent left-sided abdominal pain extending from the left hypochondrion and epigastrium down to the left lumbar region and below the umbilicus.
Radiological imaging is very important in the diagnosis of wandering spleen. Ultrasonography and computed tomography scan of the abdomen are the most useful diagnostic methods and demonstrates the absence of spleen in its normal anatomical position, with a comma-shaped structure located elsewhere in the abdomen or pelvis,  which was observed in this reported case. The spleen was shown to be multicystic on computed tomography scan. The multicystic nature of the spleen may be suggestive of parasitic infections such as malaria, hydatid disease, and splenic abscesses from varied organisms. Furthermore, in posttraumatic splenomegaly, the resolving hematoma can form or develop into a pseudocyst. However, none of these etiological agents were established in the reported case.
Treatment of wandering spleen is either splenopexy or splenectomy. Splenopexy is preferred for a viable wandering spleen to prevent future complications, especially in children.  Splenectomy is indicated in the event of acute torsion with splenic infarction. Splenectomy was carried out in the patient presented because of the massively enlarged spleen (weight = 3700 g), causing recurrent abdominal pain due to torsion and de-torsion of its pedicle. Other indications for splenectomy in wandering spleen are secondary hypersplenism, functional asplenia, and any suspicion of malignancy. 
The most common complication of wandering spleen is torsion.  Although the patient reported did not present with acute torsion, the recurrent abdominal pain may be due to torsion and de-torsion of the splenic pedicle. Other complications are splenic infarction, splenic abscess, variceal hemorrhage, and pancreatic tail necrosis. 
| Conclusion|| |
Wandering spleen should be considered as a possible cause of recurrent abdominal pain in a patient whose spleen is absent from its anatomical position on abdominal ultrasound or computed tomography scan with a demonstration of a mass elsewhere in the abdomen or in the pelvis. Increased awareness of this medical condition may help in reducing the incidence of complications.
Financial support and sponsorship
Conflicts of interest
There are no conflicts of interest.
| References|| |
Liu HT, Lau KK. Wandering spleen: An unusual association with gastric volvulus. AJR Am J Roentgenol 2007;188:W328-30.
Ben Ely A, Seguier E, Lotan G, Strauss S, Gayer G. Familial wandering spleen: A first instance. J Pediatr Surg 2008;43:E23-5.
Ugwu AC, Ogbonna CO, Imo AO. A wandering spleen: A common presentation of an anomaly. S Afr Fam Pract 2010;52:42-3.
Tabowei BI, Kombo BB. Wandering spleen - Case report. J Dent Med Sci 2013;12:88-91.
Hasan AM, Ahmad K, Sami HB. Wandering spleen: A challenging diagnosis. Pak J Med Sci 2005;21:482-4.
Safioleas MC, Stamatakos MC, Diab AI, Safioleas PM. Wandering spleen with torsion of the pedicle. Saudi Med J 2007;28:135-6.
Singla V, Galwa RP, Khandelwal N, Poornachandra KS, Dutta U, Kochhar R. Wandering spleen presenting as bleeding gastric varices. Am J Emerg Med 2008;26:637.e1-4.
Tan HH, Ooi LL, Tan D, Tan CK. Recurrent abdominal pain in a woman with a wandering spleen. Singapore Med J 2007;48:e122-4.
Misawa T, Yoshida K, Shiba H, Kobayashi S, Yanaga K. Wandering spleen with chronic torsion. Am J Surg 2008;195:504-5.
[Figure 1], [Figure 2], [Figure 3], [Figure 4]