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Avulsion of wandering spleen after traumatic torsion
Avulsion of Wandering Spleen After Traumatic Torsion By Seong-Chul Kim, Dae-Yeon Kim, and In-Koo Kim Seoul, Korea
Wandering spleen usually causes clinical symptoms by torsion. Cases of torsion or hemorrhage after blunt trauma are reported. The authors experienced avulsion of wandering spleen after traumatic torsion in the victim of pedestrian injury. The spleen had been located in the left upper quadrant on the time of torsion, but it moved into the right paracolic gutter after avulsion. The avulsed spleen was removed, and the postoperative course was uneventful.
'ANDERING SPLEEN is characterized by excessive mobility caused by laxity or absence of its suspensory ligaments. It usually causes clinical symptoms by torsion. The most common clinical presentation is a mass with intermittent pain.~ Traumatic rupture 2 or torsion 3 are reported. Treatment depends on the clinical presentation and the functional reservoir of the spleen.t Detorsion and splenopexy or splenectomy is the option. We experienced avulsion of wandering spleen after traumatic torsion.
W
J Pediatr Surg 38:622-623. Copyright 2003, Elsevier Science (USA). All rights reserved.
INDEX WORDS: Wandering spleen, splenic infarction, splenectomy, abdominal injuries.
~ -~-'t.~ •
¢
CASE REPORT A 5-year-old previously healthy boy had a pedestrian injury. He was transferred with intraperitoneal bleeding and left femur fracture after primary care and a computed tomography (CT) scan at a local hospital. He complained of abdominal pain. His vital signs were stable, and the abdomen was tender. The CT scan showed a small amount of intraperitoneal fluid and the poorly enhanced swollen spleen in the left upper quadrant (Fig 1). There was neither evidence of bowel perforation nor leakage of contrast material into the peritoneal cavity. The initial hemoglobin level was 9.2 g/dL, which dropped to 7.6 g/dL after 24 hours. After transfusion, follow-up hemoglobin levels showed no further drop. He remained stable and gained bowel activity. But on the fifth day of admission, abdominal pain was aggravated and fever developed. A rechecked CT scan showed fluid collection instead of spleen in the left upper quadrant (Fig 2A), and new fluid collection in the right paracolic gutter with rim enhancement suggesting abscess (Fig 2B). Laparotomy results showed that the spleen was avulsed into the right paracolic gutter and infarcted with preservation of its capsule. There were hematoma in the paracolic gutters; a short avulsed vascular
From the Division of Pediatric Surgery, University of Ulsan College of Medicine and Asan Medical Center, Seoul, Korea. Address reprint requests to In-Koo Kim, MD, Division of Pediatric Surgery, Asan Medical Center, 388-1, Poongnap-Dong, Songpa-Ku, Seoul 138-736, Korea. Copyright 2003, Elsevier Science (USA). All rights reserved. 0022-3468/03/3804-0022530.00/0 doi : l O.1053/jpsu.2003.50136
622
Fig 1. Abdominal CT on the day of injury shows the poorly enhanced swollen spleen in the left upper quadrant (arrow),
pedicle at the pancreatic tail with bleeding stopped; and no evidence of gastric, peritoneal or diaphragmatic attachments for the spleen in the left upper quadrant. The avulsed spleen was removed, and the postoperative course was uneventful.
DISCUSSION Wandering spleen is a rare condition characterized by excessive mobility caused by laxity or absence of its suspensory ligaments. Abell's review 4 of 97 patients in 1933 contained only one patient under the age of 10. After then, more cases in children have been reported with the most common age being less than 1 year of age. L5.6 The majority of the adult patients were female, most of whom were of reproductive age. 1.4 But in children, the gender ratio was balanced, except in the first 2 years of life when boys outnumbered girls 13 to 3. 5'6 Wandering spleen usually causes clinical symptoms by torsion. The most common clinical presentation in
Journal of Pediatric Surgery, Vol 38, No 4 (April), 2003: pp 622-623
WANDERING SPLEEN
623
f
A
m,-
9
f qk
"A~
$o
fO
Y Fig 2. Abdominal CT on the fifth day of injury shows (A) fluid collection instead of spleen in the left upper quadrant and (B) new fluid collection in the right paracolic gutter with rim enhancement suggesting abscess.
pediatric age is acute surgical emergencyP But in one review of wandering spleen in both adults and children, it presented as a mass with intermittent pain, an asymtomatic mass, or acute abdomen in order.~ Clinical diagnosis can be difficult, but imaging procedures, such as sonography, nuclear scintigraphy, computed tomography, angiography, and magnetic resonance imaging, usually are diagnostic.n Allen and Andrews 5 reported a 50% accuracy in preoperative diagnosis in children less than 10 years of age. Wandering spleen is most often found in the left lower quadrant followed by in the midabdomen or pelvis. But it can be located anywhere in the abdomen, especially after avulsion as in this case. Cases of rupture 2 or torsion 3 of wandering spleen after blunt trauma are reported. Unfortunately, we could not make a correct diagnosis of splenic torsion on his arrival, which resulted in avulsion and infarction, even if he had continued abdominal pain and tenderness and the spleen was swollen and poorly enhanced on the first CT. Delayed bleeding without tearing of splenic capsule, and the change of the location of the spleen supported secondary avuision of wandering spleen after torsion rather than primary traumatic avulsion. Treatment of wandering spleen depends on the clinical presentation and the fur[ctional reservoir of the spleen. Detorsion and splenopexy may be considered if there is no evidence of infarction, thrombosis, or hypersplenism and is especially recommended in extremely young patients who are at particular risk for overwhelming postsplenectomy infection. Splenectomy is mandatory if the spleen is infarcted or in danger of rupture or other catastrophe.
REFERENCES 1. Buehner M, Baker MS: The wandering spleen. Surg Gynecol Obstet 175:373-387, 1992 2. Horwitz JR, Black CT: Traumatic rupture of a wandering spleen in a child: Case report and literature review. J Trauma 41:348-350, 1996 3. Walcher F, Schneider G, Marzi I, et ah Torsion of a wandering spleen after blunt abdominal trauma. J Trauma 43:983-984, 1997
4. Abell I: Wandering spleen with torsion of the pedicle. Ann Surg 98:722-735, 1933 5. Allen KB, Andrews G: Pediatric wandering spleen--The case for splenopexy: Review of 35 reported cases in the literature. J Pediatr Surg 24:432-435, 1989 6. Rodkey ML, Macknin ML: Pediatric wandering spleen: Case report and review of literature. Clin Pediatr 31:289-294, 1992
Wandering spleen usually causes clinical symptoms by torsion. Cases of torsion or hemorrhage after blunt trauma are reported. The authors experienced avulsion of wandering spleen after traumatic torsion in the victim of pedestrian injury. The spleen had been located in the left upper quadrant on the time of torsion, but it moved into the right paracolic gutter after avulsion. The avulsed spleen was removed, and the postoperative course was uneventful.
'ANDERING SPLEEN is characterized by excessive mobility caused by laxity or absence of its suspensory ligaments. It usually causes clinical symptoms by torsion. The most common clinical presentation is a mass with intermittent pain.~ Traumatic rupture 2 or torsion 3 are reported. Treatment depends on the clinical presentation and the functional reservoir of the spleen.t Detorsion and splenopexy or splenectomy is the option. We experienced avulsion of wandering spleen after traumatic torsion.
W
J Pediatr Surg 38:622-623. Copyright 2003, Elsevier Science (USA). All rights reserved.
INDEX WORDS: Wandering spleen, splenic infarction, splenectomy, abdominal injuries.
~ -~-'t.~ •
¢
CASE REPORT A 5-year-old previously healthy boy had a pedestrian injury. He was transferred with intraperitoneal bleeding and left femur fracture after primary care and a computed tomography (CT) scan at a local hospital. He complained of abdominal pain. His vital signs were stable, and the abdomen was tender. The CT scan showed a small amount of intraperitoneal fluid and the poorly enhanced swollen spleen in the left upper quadrant (Fig 1). There was neither evidence of bowel perforation nor leakage of contrast material into the peritoneal cavity. The initial hemoglobin level was 9.2 g/dL, which dropped to 7.6 g/dL after 24 hours. After transfusion, follow-up hemoglobin levels showed no further drop. He remained stable and gained bowel activity. But on the fifth day of admission, abdominal pain was aggravated and fever developed. A rechecked CT scan showed fluid collection instead of spleen in the left upper quadrant (Fig 2A), and new fluid collection in the right paracolic gutter with rim enhancement suggesting abscess (Fig 2B). Laparotomy results showed that the spleen was avulsed into the right paracolic gutter and infarcted with preservation of its capsule. There were hematoma in the paracolic gutters; a short avulsed vascular
From the Division of Pediatric Surgery, University of Ulsan College of Medicine and Asan Medical Center, Seoul, Korea. Address reprint requests to In-Koo Kim, MD, Division of Pediatric Surgery, Asan Medical Center, 388-1, Poongnap-Dong, Songpa-Ku, Seoul 138-736, Korea. Copyright 2003, Elsevier Science (USA). All rights reserved. 0022-3468/03/3804-0022530.00/0 doi : l O.1053/jpsu.2003.50136
622
Fig 1. Abdominal CT on the day of injury shows the poorly enhanced swollen spleen in the left upper quadrant (arrow),
pedicle at the pancreatic tail with bleeding stopped; and no evidence of gastric, peritoneal or diaphragmatic attachments for the spleen in the left upper quadrant. The avulsed spleen was removed, and the postoperative course was uneventful.
DISCUSSION Wandering spleen is a rare condition characterized by excessive mobility caused by laxity or absence of its suspensory ligaments. Abell's review 4 of 97 patients in 1933 contained only one patient under the age of 10. After then, more cases in children have been reported with the most common age being less than 1 year of age. L5.6 The majority of the adult patients were female, most of whom were of reproductive age. 1.4 But in children, the gender ratio was balanced, except in the first 2 years of life when boys outnumbered girls 13 to 3. 5'6 Wandering spleen usually causes clinical symptoms by torsion. The most common clinical presentation in
Journal of Pediatric Surgery, Vol 38, No 4 (April), 2003: pp 622-623
WANDERING SPLEEN
623
f
A
m,-
9
f qk
"A~
$o
fO
Y Fig 2. Abdominal CT on the fifth day of injury shows (A) fluid collection instead of spleen in the left upper quadrant and (B) new fluid collection in the right paracolic gutter with rim enhancement suggesting abscess.
pediatric age is acute surgical emergencyP But in one review of wandering spleen in both adults and children, it presented as a mass with intermittent pain, an asymtomatic mass, or acute abdomen in order.~ Clinical diagnosis can be difficult, but imaging procedures, such as sonography, nuclear scintigraphy, computed tomography, angiography, and magnetic resonance imaging, usually are diagnostic.n Allen and Andrews 5 reported a 50% accuracy in preoperative diagnosis in children less than 10 years of age. Wandering spleen is most often found in the left lower quadrant followed by in the midabdomen or pelvis. But it can be located anywhere in the abdomen, especially after avulsion as in this case. Cases of rupture 2 or torsion 3 of wandering spleen after blunt trauma are reported. Unfortunately, we could not make a correct diagnosis of splenic torsion on his arrival, which resulted in avulsion and infarction, even if he had continued abdominal pain and tenderness and the spleen was swollen and poorly enhanced on the first CT. Delayed bleeding without tearing of splenic capsule, and the change of the location of the spleen supported secondary avuision of wandering spleen after torsion rather than primary traumatic avulsion. Treatment of wandering spleen depends on the clinical presentation and the fur[ctional reservoir of the spleen. Detorsion and splenopexy may be considered if there is no evidence of infarction, thrombosis, or hypersplenism and is especially recommended in extremely young patients who are at particular risk for overwhelming postsplenectomy infection. Splenectomy is mandatory if the spleen is infarcted or in danger of rupture or other catastrophe.
REFERENCES 1. Buehner M, Baker MS: The wandering spleen. Surg Gynecol Obstet 175:373-387, 1992 2. Horwitz JR, Black CT: Traumatic rupture of a wandering spleen in a child: Case report and literature review. J Trauma 41:348-350, 1996 3. Walcher F, Schneider G, Marzi I, et ah Torsion of a wandering spleen after blunt abdominal trauma. J Trauma 43:983-984, 1997
4. Abell I: Wandering spleen with torsion of the pedicle. Ann Surg 98:722-735, 1933 5. Allen KB, Andrews G: Pediatric wandering spleen--The case for splenopexy: Review of 35 reported cases in the literature. J Pediatr Surg 24:432-435, 1989 6. Rodkey ML, Macknin ML: Pediatric wandering spleen: Case report and review of literature. Clin Pediatr 31:289-294, 1992