Splenic torsion, an unusual cause of acute abdominal pain.
M Murthy, S Rajani, K Bhagheerathi
Keywords
appearance, splenic torsion, wandering spleen, whorled
Citation
M Murthy, S Rajani, K Bhagheerathi. Splenic torsion, an unusual cause of acute abdominal pain.. The Internet Journal of Radiology. 2008 Volume 10 Number 2.
Abstract
Torsion of spleen is a rare cause of acute abdominalpain leading to splenic infarction. We report a case of splenic torsion in a middle aged female and highlight the role of CT in its diagnosis.
Case history
A 36 yrs old female reported to the Casualty
Department with complaints of severe abdominal pain all over the
abdomen of few hours duration. Clinical examination revealed
nondistended abdomen with tenderness and guarding in the left
hypochondrium. USG revealed moderately enlarged spleen in a
more anterior location in left hypochondrium. Plain CT showed an
enlarged spleen in ectopic position anterior to stomach ( Fig. 1)
Figure 1
with a hyperdense foci in the vascular pedicle of spleen [ black
arrow in (Fig. 2) ].
Figure 2
representing acute thrombus secondary to stasis. CECT scan
revealed a nonenhancing enlarged spleen in the ectopic
position ( Fig. 3)
Figure 3
with a classical whorled appearance of the splenic vascular pedicle
[black arrows in ( Fig 4) ].
Figure 4
suggesting torsion with infarction. In view of these findings
laprotomy and splenectomy was done. Intraoperatively the splenic
vascular pedicle was twisted at least to 540 degrees.
Discussion
Splenic torsion is a rare cause of acute abdominal
pain due to hypermobile wandering spleen. It has been diagnosed
in approximately 0.3 % of 1,413 cases of splenectomy in a study
by Eraklis et al [1] . Wandering spleen is an uncommon condition
characterized by laxity of the supporting ligaments [2] . Incomplete
development/laxity of the anchoring ligaments of spleen –
gastrolienal, lienorenal ligaments leads to the hypermobility
resulting in wandering of spleen to an ectopic position and
subsequently torsion [3,4] . The laxity of ligament is due to the
incomplete fusion of dorsal mesogastrium with the peritoneum that
overlies the left kidney leading to the development of long vascular
pedicle contributing to hypermobility [5] .
In adults especially women, splenic torsion is attributed to acquired
abnormality such as ligament laxity, splenomegaly, trauma and
hormonal effects of pregnancy.[6]
Symptoms vary with the degree of torsion 90 – 2160 degrees,
presenting as an incidental mass on physical examination, mild
abdominal pain due to vascular congestion, acute abdomen due to
torsion of splenic pedicle with infarction [5] . Pain is usually caused
by the capsular stretching and local peritonitis [6] .
In plain radiograph, it may appear as an abdominal mass with
absence of splenic shadow in left upper quadrant or as a large mass
in the left flank[7] . Ultrasound reveals splenomegaly with
heterogenous echotexture in ectopic position. Color Doppler shows
decreased perfusion due to torsion [8]. CECT reveals the ectopic
position of the enlarged spleen with little or no contrast
enhancement [5,8]. Swischuk et al[3] described the whorled
appearance of the twisted vascular pedicle of spleen as a valuable
finding in making the diagnosis.
The current treatment for splenic torsion with infarction is
Splenectomy [4,7].