Wandering spleen and splenic torsion: Recognition of a pelvic mass mimicker

A 20-year-old primiparous woman presented at the gynecologist with persisting lower abdominal discomfort, pain and an increase in urinary frequency. Routine gynecologic work-up revealed a large mass, located in the lower left pelvic area. A left ovarian mass was suspected. The patient was referred for a pelvic computed tomography (CT) investigation.

An axial CT image shows a large, well-circumscribed comma-shaped intrapelvic mass which is hypodense on non-enhanced series (Fig 1a) and is enhancing homogeneously after contrast administration on venous phase (Fig 1b), with displacement of the uterus to the right.

A contrast-enhanced fat-saturated axial T1 vibe image demonstrates a well-circumscribed and homogenous enhancing mass in the lower abdomen with internal vascular structures merging in a central point (yellow arrows). (Fig 2)

Additionally, a rotated vascular pedicle can be identified in the left hemi-abdomen inducing a whirl sign (yellow arrow). (Fig 3)

A coronal post-contrast T1 vibe image displays the tortuous vascular pedicle (yellow arrows). Note that the spleen is missing in the left upper quadrant. (Fig 4)

On laparoscopic images, an enlarged and mildly congestive spleen can be recognized (Fig 5a) caused by the pedicle rotated around its own axis (Fib 5b).

A wandering spleen or ectopic spleen is a hypermobile spleen attached only by a long vascular pedicle, which allows it to migrate in the whole abdomen. Without the function of the suspensory ligaments, this state is prone to splenic torsion. [1-3]

There are two major incidence peaks. The first is observed in children under 1 year, due to aplasia or hypoplasia of the splenic suspensory ligaments. The second incidence peak occurs in the third life decade, mostly in women. Stress on the abdominal wall and suspensory ligaments is believed to be the cause in this group, for example, pregnancies and diseases causing splenomegaly. [1-3]

Symptoms are related to abdominal mass with mass tenderness and associated gastrointestinal complaints. Splenic torsion can cause splenic vein occlusion and congestion. It’s possible for the spleen to get ischemic and infarcted, which usually mimics an acute abdomen. [1,2]

Most important signs on radiologic investigations are a comma-shaped mass with a vascular pedicle and the absence of the spleen in the left upper quadrant (LUQ). A whirl sign can be seen in case of splenic torsion. CT is the modality of choice because it’s more readily available, although magnetic resonance (MR) has similar sensitivity and specificity in detection of wandering spleen and splenic torsion. In unenhanced CT, a hyperdense vessel suggests a thrombus. Contrast-enhanced CT is important to assess the viability of the splenic parenchyma. [1-3,5]

Ultrasound (US) can also be useful, especially Doppler-investigation for assessment of the vascular pedicle and viability of splenic parenchyma. When a comma-shaped mass is detected during US-examination, a missing spleen in LUQ is almost pathognomic in the diagnosis of wandering spleen. [1,2,5]

Radiographs are non-specific but the condition can be suspected when there is a mass in an abnormal location and when the splenic shadow isn’t seen in the LUQ. [1,5]

Surgery is almost mandatory in wandering spleen cases, since asymptomatic cases are associated with a high complication rate, up to 65%. [7] Whenever possible, laparoscopic splenopexy is the treatment of choice. Preservation of the spleen should be a priority, especially in children. In splenic torsion, laparoscopic derotation is the first step in the surgical treatment. If the congested spleen recovers, a splenopexy can be performed. If there’s an infarcted spleen, a splenectomy should be performed. After splenectomy, patients must be treated against encapsulated bacteria to prevent overwhelming post-splenectomy infections. [1,6,7]

Written informed patient consent for publication has been obtained.