Introduction

Wandering spleen is a rare clinical entity characterized by absence of normal ligamentous attachments of the spleen and laxity of the splenic pedicle. This condition is also known as floating spleen, drifting spleen, systopic spleen and splenoptosis. An uncomplicated mobile spleen presents as a freely mobile abdominal lump which poses a diagnostic challenge due to lack of awareness and paucity of symptoms. We report a case of pelvic wandering spleen with huge splenomegaly.

Case Report

A 30-year-old lady presented with a six-month history of a lump and vague discomfort in the abdomen. There was no gastrointestinal symptom but she had increased frequency of micturition. Her physical examination was unremarkable. Abdominal examination revealed an intra-abdominal lump on the left side occupying pelvic; umbilical and lumbar region. It was firm and non-tender with smooth surface and freely mobile in all directions. Hemogram, urine, stool, blood biochemistry, plain x-rays, chest and abdomen were normal.

General blood picture reported no abnormal cells. Ultrasonography reported the swelling as a homogenous mass arising from the pelvis and compressing the urinary bladder. CT scan of the abdomen reported an enlarged spleen (22cm) in ectopic location extending from the level of the renal hilum anterior to the left kidney to the supravesical region, compressing the urinary bladder and displacing surrounding bowel (Figure 1).

Figure 1

Figure 1: CT scan of the abdomen showing a huge spleen in the pelvis

Exploratory laparotomy was performed under general anaesthesia. A huge enlarged spleen with a long pedicle was seen (Figure 2).

Figure 2

Figure 2: A huge enlarged spleen with long pedicle

Gastrosplenic and lieno-renal ligaments were absent. Splenectomy was performed easily with ligation of the splenic pedicle. The post-operative period was uneventful and the patient was discharged on the 10^th post-operative day. Histopathology report was normal.

Discussion

Wandering spleen is a condition characterized by absence of the normal ligamentous attachments of the spleen. Because of lack of fixation and an unduly long pedicle the spleen “wanders” in the abdominal cavity and pelvis, where it can be mistaken for an unidentified abdominal mass. Until now nearly 500 cases of wandering spleen have been reported₁. It usually occurs in women of 20-40 years and children below 10 years of age. The reported incidence based on splenectomies for all ages is 0.16%₂₃. The bimodal age incidence favors congenital and acquired etiological factors₄. Malformations or absence of splenic attachments like lienorenal and/or gastrosplenic ligaments with long splenic pedicle have been described, as in our case₅.

Clinical diagnosis of Wandering Spleen is difficult, it may be confused with enlarged kidneys or tumors of renal, ovarian, uterine or colonic origin. It may present as a asymptomatic incidental finding on physical or radiological examination or with acute abdomen as a result of torsion and infarction₆₇.

However, the most common presentation is an abdominal mass with non-specific symptoms like ischuria, constipation and pelvic discomfort. Hypersplenism, thrombocytopenia and lymphoma have also been described with wandering spleen₈.

Diagnosis can be confirmed by various imaging modalities like ultrasonography, CT scan and scintigraphy. In our case, diagnosis was made on CT scanning which has an additional advantage as it demonstrates the organ’s circulation and viability. Duplex ultrasonography can provide similar information but it is operator-dependent₉.

Treatment of choice for wandering spleen is operative splenopexy, open or laparoscopic, for uncomplicated spleen due to complications like torsion and infarction.₁₀₁₁₁₂ Splenectomy is done when there is compromised blood flow and in cases of splenomegaly which preclude splenopexy as in our case₅.

Correspondence to

Dr. Shahi K. S., MS, FICS, FAIS Kamal Kunj, Rampur Road, North Manpur, Haldwani Nainital-Pin. 263139, Mob.: 09412906925 Ph.: 05946 – 234442, E-mail: kedar_shahi@rediffmail.com