Abstract: 13-year-old male presented to the emergency department (ED) with a
2-day history of acute left-sided sharp abdominal pain. The patient
denies any trauma, fever, or vomiting. The patient presented to the ED
initially and was diagnosed with constipation and discharged home after
his abdominal pain subsided. After discharge, the patient’s abdominal
pain became unbearable due to the pain and returned to the ED.
Physical exam was significant for abdominal tenderness and guarding. Initial
laboratory findings were unremarkable. The patient’s abdominal pain
continued to worsen and therefore a computed tomography (CT) scan of the
abdomen and pelvis was ordered (Figures 1 and 2).
Accessory splenic infarct with torsion
Differential diagnosis: hematoma, lymphadenitis, neoplasm
The CT scan revealed a 2.7-cm mass in the left upper quadrant anterior to the
spleen with surrounding inflammatory changes and slightly decreased
contrast enhancement as compared with the spleen.
Accessory spleen is a common, usually a symptomatic finding that appears in 10% to 30% of autopsies.1
An accessory spleen originates from incomplete fusion of the
mesenchymal buds. The accessory spleen may be pulled by splenic
ligaments to ectopic locations.1 They are always located on
the left side of the abdomen, due to the rotation of the spleen during
embryogenesis. The sites of an accessory spleen is the splenic hilum
(75%), and pancreatic tail (20%).1 Accessory spleens can be either solitary or multiple and receive their vascular supply from branches of the splenic artery.
Very rare complications do occur with an accessory spleen, such as torsion with infarction, rupture, and/or infection.2,3,4
Patients may present as an acute abdomen or with history of recurrent
bouts of intermittent abdominal pain. Intermittent torsion and detorsion
causes these recurrent bouts of pain due to short-lasting ischemia or
from direct mechanical irritation to the adjacent organs.6
Torsion of the accessory spleen with resultant infarction and necrosis
may be secondary to twisting of the vascular pedicle twisting (Figure
Most accessory spleens have a characteristic
appearance on CT. They may appear as well-marginated, round masses that
are smaller than 2 cm.7 Another important feature is
homogenous enhancement on contrast-enhanced images. Similarly, accessory
spleens may be differentiated from metastatic lesions or
lymphadenopathy in the splenic hilum when they enhance to the same
degree as the spleen.7
In all previously reported cases with torsion of an accessory spleen, the diagnosis was made in the operating room.1
The pediatric radiologist on staff made the diagnosis preoperatively,
which raises the question of whether or not the diagnosis of an
accessory spleen can preoperatively prevent surgery? Jaroch et al
proposed uncomplicated splenic infarction can be managed safely with
medical treatment, but splenectomy is performed for persistent symptoms
or a complication of the infarct (splenic pseudocyst, abscess, or
hemorrhage) to lower the mortality rate.8
While abdominal pain in the pediatric population is quite common, making
the correct diagnosis can be challenging. Uncommon causes of abdominal
pain may make for a complex differential diagnosis. This case highlights
the possibility of a preoperative diagnosis and features of accessory
splenic infarct with torsion on CT. Proper radiological diagnosis may
raise the possibility of nonsurgical intervention.
- Impellizzeri P, Montalto AS, Borruto FA, et al.
Accessory spleen torsion: Rare cause of acute abdomen in children and
review of literature. J Pediatr Surg. 2009;44:e15-18.
Seo T, Ito T, Watanabe Y, et al. Torsion of an accessory spleen
presenting as an acute abdomen with an inflammatory mass. US, CT, and
MRI findings. Pediatr Radiol. 1994;24:532-534.
- Habib FA, Kolachalam RB, Swason K. Abscess of an accessory spleen. Am Surg. 2000;66:215-218.
Coote JM, Eyers PS, Walker A, et al. Intra-abdominal bleeding caused by
spontaneous rupture of an accessory spleen: the CT-findings. Clin Radiol. 1999;54:689-691.
- Nores M, Phillips EH, Morgenstern L. The clinical spectrum of splenic infarction. Am Surg. 1998;64:182-188.
- Wacha M, Danis J, Wayand W. Laparoscopic resection of an accessory spleen in a patient with chronic lower abdominal pain. Surg Endosc. 2002;16:1242-1243.
- Mortele KJ, Mortele B, Silverman SG. CT features of the accessory spleen. AJR Am J Roentgenol. 2004;183:1653-1657.
- Jaroch MT, Broughan TA, Hermann RE. The natural history of splenic infarction. Surgery. 1986; 100:743-750.