Case Report Splenosis: a Rare Etiology for Bowel Obstruction—A Case Report and Review of the Literature

Hindawi Publishing Corporation Case Reports in Surgery Volume 2015, Article ID 890602, 4 pages http://dx.doi.org/10.1155/2015/890602 Case Report Splenosis: A Rare Etiology for Bowel Obstruction—A Case Report and Review of the Literature George Younan,1,2 Edward Wills,2 and Gordon Hafner2 1 DivisionofSurgicalOncology,DepartmentofSurgery,MedicalCollegeofWisconsin,9200W.WisconsinAvenue, Milwaukee, WI 53226, USA 2DepartmentofSurgery,InovaFairfaxHospital,3300GallowsRoad,FallsChurch,VA22041,USA Correspondence should be addressed to George Younan; [email protected] Received 8 September 2015; Accepted 27 September 2015 Academic Editor: Akihiro Cho Copyright © 2015 George Younan et al. This is an open access article distributed under the Creative Commons Attribution License, which permits unrestricted use, distribution, and reproduction in any medium, provided the original work is properly cited. Splenosis is a historically uncommon etiology for bowel obstruction. Autotransplanted splenic tissues following surgery or trauma of the spleen are known to occur in multiple locations of the abdominal cavity and pelvis. The small bowel mesentery is a blood vessel-rich environment for growth of splenic fragments. We present a case of a 36-year-old male patient who sustained a gunshot wound to his left abdomen requiring a splenectomy and bowel resection fifteen years prior to his presentation with small bowel obstruction requiring exploration, adhesiolysis, and resection of the mesenteric splenic deposit. Our aim in this report is to provide awareness of splenosis as an etiology for bowel obstruction, especially with increased incidence and survival following abdominal traumas requiring splenectomies. We also stress on the importance of history and physical examination to include splenosis on the list of differential diagnoses for bowel obstruction. 1. Introduction previous episodes of obstruction resolved with nonoperative management, his recent one required surgical exploration. A Splenic fragments after trauma or surgery have the ability preoperative abdominal film showed the remaining gunshot to heterotopically autotransplant onto vascularized intra- or shrapnel (Figure 1(a)), and a preoperative CT scan showed extraperitoneal surfaces [1, 2]. Most common locations of a transition point in the left upper quadrant and a small splenic deposits are in the vicinity of the left upper quadrant, 2 × 3 cm hyperintense mass (Figures 1(b) and 1(c)). Upon typically involving the serosal surfaces of small and large exploration and adhesiolysis, a well-contoured, dark blue bowel, the greater omentum, and diaphragm, but sometimes mass was found in the small bowel mesentery at the transition they can grow in the nearby mesentery or be found in very point, correlating to the CT scan findings and causing unusual locations [3–5]. Most cases are asymptomatic and scarring and shortening of the mesentery resulting in a are incidentally diagnosed during imaging studies or surgical mechanical small bowel obstruction. The mass was resected explorations for other conditions [1, 6]. We present in this off the mesentery and sent for pathology which showed that report a case of mesenteric splenosis resulting in adhesive it consisted with a splenosis deposit with architecture of small obstruction requiring exploration, adhesiolysis, and nodules of splenic tissue, surrounded by thick connective splenosis resection. tissue trabeculae (Figure 2). The patient recovered and was discharged home on a regular diet. 2. Case Presentation A 36-year-old man with a history of a gunshot trauma to 3. Discussion the left upper quadrant at the age of thirty-one, requiring multiple operations, including a splenectomy, resulting in Ectopic splenic tissues are classified into two types, congenital recurrent small bowel obstructions over fifteen years. While and acquired. Failure of union of the normal spleen during 2 Case Reports in Surgery (a) (b) (c) Figure 1: Abdominal X-ray shown in (a), depicting the number of shrapnel left in the left side of the body after the gunshot injury, in addition to dilated loops of bowel. CT scan with oral and intravenous contrast shows the splenosis deposit (white arrow) in axial (b) and coronal (c) views. (a) (b) Figure 2: H&E stained slides of the splenosis deposit showing splenosis architecture. Splenic nodules separated by strands of fibrous trabeculae (a). White and red pulp nodules are seen (b). embryogenesis results in formation of accessory spleens. and Lipkoff in 1939 were the first to use the term “splenosis” These are common and found in 20% of people [7]. They [15]. The majority of splenosis cases occur after traumatic have a normal splenic histological architecture and function splenectomies, whereas a few are the result of elective and commonly are found in the splenic hilum and the splenectomies done for hematological diseases [1, 4]. A few gastrosplenic, splenorenal, or splenocolic ligaments and they reviews cite that traumatic splenosis is responsible for up to get their blood supply from a branch of the splenic artery [7, 93% of all splenosis cases [1, 12, 16]. There are reports that 8]. Splenosis is an acquired form of ectopic splenic tissues that splenosis occurs in 16%–67% of patients after splenectomies gained function and perfusion after autotransplantation onto for trauma or hematological diseases [11, 16–18]. The mean blood vessel-rich intra- or extraperitoneal environments; as interval between a splenectomy and the clinical diagnosis of a result their blood vessels are not related to the splenic splenosisvariesfromafewmonthsuptofourdecades[1,12]. artery [1, 9]. The mechanism of spread of splenic fragments is Most of the splenoses are asymptomatic and deposits believed to be either by a direct seeding process onto adjacent are found incidentally on imaging studies or explorations surfaces or by hematological spread to distant organs such as done for other pathologies [19]. Ectopic splenic tissues after the liver, breast, and brain [10, 11]. In support of the seeding a splenectomy are either beneficial or harmful depending process hypothesis, splenosis deposits are found in the chest on the etiology leading to the splenectomy. Whereas splenic in cases of traumatic diaphragmatic rupture exclusively in the tissues provide some salvage splenic function after trau- left hemithorax, in subcutaneous locations where port sites matic splenectomies, they usually are functional enough to were introduced, and in exit wounds after gunshot wounds cause recurrence of hematological diseases that the original that involved the spleen [1, 7, 12, 13]. splenectomies were meant to treat [16, 20, 21]. In addi- The first report of a splenosis case dates back to 1896; tion, the risk of overwhelming postsplenectomy infection it was described by Albrecht in Germany [14]. Buchbinder appears to be lower in trauma cases compared to elective Case Reports in Surgery 3 Table 1 Author Journal Year Type of obstruction Procedure Journal of Gastrointestinal Left hemicolectomy, Obokhare et al. [6] 2012 Colon Surgery appendectomy Gincu et al. [22] Endoscopy 2011 Colon Resection of mass World Journal of Lysis of adhesions, Garaci et al. [23] 2009 Small bowel Gastroenterology resectionofrectalmass Pediatric Surgery Laparotomy, lysis of Sato et al. [24] 2007 Small bowel International adhesions Small bowel Laparoscopic-assisted small Abeles and Bego [25] Surgical Endoscopy 2003 (intussusception) bowel resection Laparotomy, lysis of Sirinek et al. [26] Southern Medical Journal 1984 Small bowel adhesions splenectomies [21]. Whether the actual splenosis deposits splenectomized patients to avoid invasive procedures, given confer such benefit and whether the matter of autologic that asymptomatic splenosis deposits pose no risk and can be splenic transplantation after a traumatic splenectomy would left unresected. be beneficial are still a matter of debate [27]. Splenosis tissues cause one of three surgically significant conditions: intra- or Conflict of Interests extraluminal bleeding, local compression of adjacent tissues and organs, and misdiagnoses worrisome for tumors leading The authors declare that there is no conflict of interests to unnecessary surgical explorations. Accessory spleens how- regarding the publication of this paper. ever rarely cause these conditions [28, 29]. Diagnosis of splenosis, as mentioned above, is in general confirmed after imaging studies and surgical explorations Authors’ Contribution for other conditions. In our patient, it was diagnosed after George Younan and Edward Wills equally contributed to this exploration for adhesiolysis and relief of the small bowel work. obstruction, which should be and was done irrespective of the splenosis diagnosis. However a high level of suspicion should be exercised in cases where an unnecessary procedure References can be avoided, especially in patients with a history of [1] D. Ksiadzyna and A. S. Pena,˜ “Abdominal splenosis,” Revista splenectomy [30]. In addition to a proper history and physical Espanola de Enfermedades Digestivas,vol.103,no.8,pp.421– exam, a blood smear showing the absence of Howell-Jolly, 426, 2011. Pappenheimer, or Heinz bodies is indicative of the presence [2] S. Akay, A. T. Ilica, B. Battal, B. Karaman, and I. Guvenc, of functional splenic tissues. However, at this day and age, “Pararectal mass: An atypical location of splenosis,” Journal of imaging studies evolved to accurately diagnose splenosis Clinical Ultrasound,vol.40,no.7,pp.443–447,2012. deposits. Standard CT and MRI

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