‘Wandering spleen with acute torsion’ : a rare indication for splenectomy in an adult, complicated by postoperative splanchnic venous thrombosis and intestinal gangrene

Abstract

Wandering spleen (WS) is a hypermobile spleen that, due to the laxity of its ligaments, is prone to torsion. We report a case of a 45-year-old multiparous woman who presented with acute abdominal pain and a tender palpable mass. A contrast-enhanced computed tomography scan of the abdomen showed a WS with torsion. She underwent an emergency splenectomy and was discharged after an uneventful recovery. She was readmitted with splanchnic venous thrombosis and was managed with therapeutic low-molecular-weight heparin (LMWH) and discharged. Twenty days later, she presented with new-onset abdominal pain. She had not complied with LMWH as advised. The thrombosis had progressed, leading to small bowel gangrene, requiring resection and a stoma. Due to frequent metabolic disturbances, an early reversal of stoma was performed. She was lost to follow-up thereafter. This case highlights a rare indication for emergency splenectomy and one of its major postoperative complications.

Wandering spleen with acute torsion mimicking an adnexal mass

“…Wandering spleen is an uncommon condition, with a worldwide prevalence of less than 0.2% [10] , however, due to underreporting and asymptomatic cases, the actual value is unknown [6] . Usually, wandering spleen presents in young children, and in adulthood, typically in females between the ages of 20 and 40 years.…”

“…Developmental anomalies can lead to no ligaments being present, furthermore, the inability of the dorsal mesogatrium to merge with the posterior abdominal wall during embryonic life can lead to a long splenic pedicle [7] . Weaking of the ligaments has been associated with hormonal fluctuations in pregnancy (with an increased association in multiparous females), splenomegaly due to malaria and certain anemias, trauma, abdominal weakness [6] , Hodgkin's disease, Gauchers disease, and kidney abnormalities [5] .…”

“…Studies have shown that splenic torsion can complicate up to 65% of wandering spleen pediatric patient cases, leading to either irreversible splenic ischemia or gastric volvulus [ 14 ]. Additional complications include but are not limited to splenic vein thrombosis, portal hypertension, gastric varices, and peritonitis [6] . Often, the abdominal pain due to splenic torsion is mistaken for appendicitis, cholecystitis, or general acute abdomen [7] , thus making thorough investigations crucial for diagnosis.…”

“…Upon clinical examination, a hard, movable, palpable mass can be appreciated in the left upper quadrant, and resonance is observed upon percussion. The notched border of the spleen is sometimes obscured upon palpation due to splenic enlargement secondary to torsion [6] . Laboratory findings are also nonspecific; however, impairment of splenic function can reveal itself on blood smears as Howell-Jowell bodies [ 15 ], or as pancytopenia on blood counts [7] .…”

“…This subsequently causes strangulation, necrosis, venous congestion, and edema [5] . Other complications include peritonitis, splenic vein thrombosis, left-sided portal hypertension, and splenic hemorrhage [6] . The causes of wandering spleen are either congenital, such as underdevelopment of the splenic ligaments [7] , or acquired, due to multiple pregnancies, splenomegaly, or connective tissue disorders [ 7 , 8 ].…”