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Weird Activity and the Wandering Spleen

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Weird Activity and the Wandering Spleen Case Communications Weird Activity and the Wandering Spleen Nehama Sharon MD1, Jacob Schachter MD2, Ruth Talnir MD MBBCh MSc2, Joel First MD2, Uri Rubinstein MD2 and Ron Bilik MD3 Departments of 1Pediatric Hemato-Oncology and 2Pediatrics, Sanz Medical Center, Laniado Hospital, Netanya, Israel 3Department of Pediatric Surgery, Sheba Medical Center, Tel Hashomer, Israel Key words: wandering spleen, Doppler ultrasound, splenectomy IMAJ 2005;7:744–745 A wandering spleen is a rare form of de- in the splenic vein. There was A velopmental anomaly of the dorsal meso- a small amount of peritoneal gastrium of the spleen, leading to failure fluid around the liver and in the or incomplete attachment of the splenic pouch of Douglas. The examiner ligaments to the diaphragm, retroperi- commented on the mobility toneum and colon. Laxity of the sus- of the spleen and raised the pensory ligaments of the spleen can be possibility that it could be a congenital or acquired. These two forms wandering spleen. A computed of developmental anomalies result in the tomography-angiography scan of formation of a long vascular pedicle and the abdomen showed that the variable intraperitoneal splenic mobility stomach was grossly distended depending on the length of the vascular into the left upper quadrant pedicle. We describe here an acute tor- normally occupied by the spleen sion of a wandering spleen in a child fol- [Figure A]. The spleen was [A] Grossly distended stomach occupying the left upper quadrant normally occupied by the spleen. lowing an unusual physical activity. enlarged and located in the left lower quadrant of the abdomen, B Patient Description encroaching the pelvic inlet. A 7.5 year old boy was admitted to our There was no enhancement ward because of sudden onset of vomit- following injection of contrast ing and colicky abdominal pain lasting medium. The splenic artery was several hours. The boy was well until sev- narrowed [Figure B]. eral hours before his admission and his The child was admitted but past medical history was non-contribu- deteriorated clinically, and as tory. On further inquiry it was discovered the blood count showed a drop that a week prior to his admission he in hemoglobin level to 8.8 mg/ had occupied himself doing headstands. dl, an emergency laparoscopy Physical examination on admission was performed. Examination revealed a thin, pale and apprehensive revealed an enlarged, congest- child. His temperature was 36.5ºC, blood ed spleen with torsion, findings [B] Enlarged spleen located in the left lower pressure 114/74 and pulse 96 regular. On that necessitated the removal quadrant of the abdomen encroaching the pelvic palpation the abdomen was diffusely ten- of the spleen. inlet. No enhancement appears following injection of contrast medium. The splenic artery is narrowed. der with an extremely enlarged and hard The postoperative course was mass. The rest of the physical examina- uneventful; the boy received tion was unremarkable. Laboratory analy- pneumococcal, meningococcal sis on admission showed hemoglobin and Haemophilus influenzae vac- 11.7 mg/dl, mean cell volume 87, white cines and was discharged home with am- mon clinical finding. Normally the spleen blood cells 9,000/mm³ with neutrophilia, bulatory follow-up. On examination 1 year is fixed in its position in the left upper and platelets 300,000/mm³. Electrolytes, later the child was doing well and his quadrant by three main suspensory liga- amylase and liver function tests were blood counts were within normal range. ments. A wandering spleen arises from within normal range. either a congenital or acquired laxity of Doppler ultrasound examination of the Comment the suspensory ligaments of the spleen, abdomen revealed an enlarged spleen A wandering spleen is a rare form of or a congenital fusion anomaly of the measuring 12.7 cm in length with no flow developmental anomaly and an uncom- posterior leaf of the dorsal mesogastrium 744 N. Sharon et al. • Vol 7 • November 2005 Case Communications of the spleen with the parietal peritone- from its position and precipitated the as bleeding or rupture, fixing the spleen um [1]. These developmental anomalies acute event of splenic torsion. is the definitive treatment. In recent result in failure or incomplete attachment There are various diagnostic modalities years various techniques of laparoscopic of the spleen to the diaphragm, retro- to demonstrate a wandering spleen and splenopexy have replaced the more peritoneum and colon, or a formation suspected torsion. A plain abdominal traditional laparotomy as the preferred of a long vascular pedicle and variable X-ray in the supine and erect position procedure [5]. In cases of torsion in intraperitoneal splenic mobility. The inci- show the spleen as a mobile mass in the which the spleen cannot be salvaged after dence of a wandering spleen in the gen- left or central abdomen and the normal detorsion, splenectomy is performed. eral population is unknown. It is more splenic contour in the left upper quadrant In conclusion, a wandering spleen common in adult females (7:1). Children is absent. Ultrasonography shows absence is a rare clinical finding, especially in make up one-third of all cases, a third of of the spleen in its usual site in the children. This diagnosis should be con- them under the age of 10 years, with an left upper quadrant and a homogenous, sidered whenever there are signs and equal male to female ratio. hypoechoic or anechoic mobile mass in symptoms of an acute abdomen or dur- Clinical presentation includes the left flank, mid-abdomen or pelvis [3]. ing investigations of chronic intermittent an incidental finding of a painless Power Doppler sonography is preferable abdominal pain. abdominal or pelvic mass, chronic to duplex and color Doppler for detecting intermittent non-specific abdominal or weak blood flow in the splenic vessels. References pelvic pain as a result of spontaneous Radionuclide scan is valuable for assessing 1. Robinson AP. Wandering spleen: case re- torsion and detorsion of the splenic splenic function. It shows normal uptake port and review. Mt Sinai J Med 1988;55: pedicle, and a mass on palpation. Most in an abnormally positioned spleen or 428–34. ectopic spleens are enlarged because of in cases of torsion and infarction there 2. Lamesch P, Lamesch A. Anomalies of the position of the spleen in the child. venous congestion, and the inflammatory will be no uptake of isotope on a scan Langenbecks Arch Chir 1993;378:171–8. reaction secondary to ischemia and and the spleen will not be demonstrated. 3. Belet U, Akan H, Kazanci F, et al. Tor- traction by the enlarged spleen elongates CT scan with contrast medium shows sion of a wandering spleen. Radiologic the vascular pedicle and contributes abnormal position of the spleen and assessment in one case. Radiol Med (To- to the development of torsion [2]. In delineates the anatomic position of rino) 1998;95:125 4. Fujiwara T, Takehara Y, Isoda H, et al. about 50–65% of cases the presenting other abdominal structures. In cases of Torsion of the wandering spleen: CT and symptoms are those of an acute torsion or infarction a CT-angiography angiographic appearance. J Comput Assist abdominal event. In two-thirds of these demonstrates lack of blood flow in the Tomogr 1995;19:84–6. patients no symptoms preceded the acute splenic pedicle and lack of enhancement 5. Hirose R, Kitano S, Bando T, et al. Lap- event. Fever, vomiting and leukocytosis following injection of contrast medium aroscopic splenopexy for pediatric wan- dering spleen. J Pediatr Surg 1998;33(10): often accompany the acute abdominal [4]. The modalities of choice for definite 1571–3. symptoms. Precipitating factors in the diagnosis are Doppler ultrasound and CT development of torsion include changes of the abdomen. Surgery is required for Correspondence: Dr. N. Sharon, Head, in intra-abdominal pressure during a wandering spleen and the definitive Dept. of Pediatric Hemato-Oncology, Lania- respiration or peristalsis or distension procedure depends on whether the do Hospital, Kiryat Sanz, Netanya 42150, of adjacent organs, abdominal trauma spleen is viable or not. Because of the Israel. and movements of the body. In the case high incidence of torsion of a wandering Phone: (972-540) 430-3351 described here, the unusual physical spleen even in asymptomatic patients and Fax: (972-9) 860-4748 activity probably displaced the spleen the increased risk of splenic trauma such email: [email protected] Capsule Hypothalmic glucose monitor The brain, and in particular, the hypothalamus, controls adenosine triphosphate (ATP) production. Alterations in ATP liver glucose production, but the cellular and molecular levels control neuronal excitability through effects on ATP- mechanisms by which the brain senses glucose levels have sensitive potassium channels, which have been implicated been unclear. Lam and team show that, in rats, this process in glucose output by the liver. requires the conversion of glucose in the hypothalamus to Science 2005;309:943 lactate, which in turn stimulates pyruvate metabolism and Eitan Israeli • Vol 7 • November 2005 Wandering Spleen 745.
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