Prepared by Manzoor Ahmed, MD and Thomas Poulton, MD of the
Department of Radiology, Aultman Hospital, Canton, OH.
A 15-year-old white girl presented to the emergency room with
acute mid-abdominal pain, nausea, and vomiting. Her medical history
was remarkable only for autoimmune hepatitis. On physical
examination, a tender palpable mass was present in the lower
abdomen and pelvis. Contrast-enhanced computed tomography (CT)
(figure 1) and abdominal ultrasound (US) (figure 2) were
Wandering spleen with torsion
Contrast-enhanced CT of the abdomen and pelvis demonstrated the
absence of the spleen in the left upper quadrant, with the normal
spleen bed replaced by bowel gas (figure 1A). An enlarged spleen is
located abnormally in the lower abdomen and upper pelvis, and it
showed a lack of enhancement with a "whorled" appearance of its
pedicle (figures 1B and C) consistent with torsion. Abdominal US
was performed to confirm torsion as shown by the absence of Doppler
flow to the spleen (figure 2). Splenectomy was performed. Surgical
and pathologic findings confirmed wandering spleen with
Wandering spleen means an abnormally located spleen with a long
It is a rare cause of acute abdomen,
and is usually quiescent unless transient or persistent torsion of
its pedicle occurs. Timely preoperative diagnosis is required to
avoid potential complications such as hemorrhagic infarction,
splenic gangrene, formation of a cyst or abscess, and development
of pancreatic tail necrosis.
In their review of 1413 cases of splenectomies, Erkalis and Filler
found only 4 reported cases of wandering spleen. Similarly, Broker
documented 3 cases during a 24-year period, while Allen and Andrew
reprted 35 cases of wandering spleen in children, most of whom
presented as acute emergencies.
While the reported age incidence of wandering spleen ranges from
3 months to 98 years,
it is found typically in children under 10 years of age. This
condition has no gender predominance,
and is common in patients of African descent.
Asymptomatic patients may present with splenomegaly or abdominal
mass. Symptomatic patients present with either intermittent mild
abdominal pain (due to torsion and spontaneous detorsion) or frank
acute abdomen from torsion of the splenic pedicle and impending
In children, the typical etiology is abnormal development of
dorsal mesogastrium; in adults, possible causes include laxity of
ligaments, splenomegaly, and trauma.
The spleen and its main supporting structures, the lienorenal and
gastrolienal ligaments, arise in the dorsal mesogastrium. These
ligaments stabilize the spleen, but do allow some mobility. The
lienorenal ligament is formed by fusion of the posterior leaf of
dorsal mesogastrium with parietal peritoneum. In the process, the
pancreas acquires its retroperitoneal location. Incomplete fusion
results in a long pedicle, which may include the distal tail of the
The splenocolic, splenophrenic, and phrenicolic ligaments are other
supporting structures. The phrenicolic ligament forms a resting
slip for the spleen.
Ultrasound is usually one of the first studies performed for
evaluation of an abdominal mass. On sonography, the wandering
spleen with torsion appears enlarged and may show subcapsular
Doppler flow is absent in complete torsion, as was evident in this
case. Plain films may show nonspecific findings, such as the
absence of a splenic shadow in left upper quadrant replaced by
bowel gas, and mass effect in the lower abdomen or pelvis.
CT manifestations have been well described, including the absence
of the spleen in its normal location, lower abdominal or pelvic
mass, whorled appearance of the splenic pedicle, ascites,
pancreatic tail necrosis, and pseudocapsule (in chronic torsion).
Scintigraphy with Tc99m sulfur colloid can show the abnormal
location and function of the spleen (ie, diminished function or no
uptake), but nonvisualization of the spleen is a nonspecific
finding that can also be seen in functional asplenia.
Angiography is an option for the definitive diagnosis of torsion or
may be obtained pre-operatively to define vascular detail.
Splenectomy is the treatment for acute torsion. Splenopexy is an
option for a noninfarcted spleen.
The pancreatic tail should be inspected for necrosis at the time of