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 Table of Contents  
CASE REPORT
Year : 2019  |  Volume : 52  |  Issue : 5  |  Page : 189-192

Recurrent abdominal pain with thrombocytosis:A presentation of wandering spleen


1 Department of Surgery, Faculty of Medicine for Girls, Al-Azhar University, Cairo, Egypt; Department of Surgery, College of Medicine, Jouf University, Sakakah, Saudi Arabia
2 Department of Surgery, Faculty of Medicine for Girls, Al-Azhar University, Cairo, Egypt

Date of Submission09-Apr-2019
Date of Decision24-Apr-2019
Date of Acceptance23-Jul-2019
Date of Web Publication25-Oct-2019

Correspondence Address:
Dr. Hany Abdelfatah Elhady
Department of Surgery, Faculty of Medicine for Girls, Al-Azhar University, Cairo, Egypt. College of Medicine, Jouf University, Sakaka

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Source of Support: None, Conflict of Interest: None


DOI: 10.4103/fjs.fjs_34_19

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  Abstract 


Splenic congenital anomalies are many. Wandering spleen (WS) is a rare anomaly account for about 0.2%. It is usually associated with absent or maldevelopment of one or all splenic ligaments that hold the spleen in its place. A 15-year-old girl had complaints of repeated attacks of mid-abdominal pain for the last month. Abdominal examination revealed a central fixed and slightly tender abdominal mass in the umbilical region. Complete blood count revealed platelets (790 × 103/mL), white blood cells (9700 × 103/mL), and hemoglobin (8 g/dL), and other investigations were normal, but unfortunately ultrasound and computed tomography report revealed WS. Abdominal exploration revealed the spleen not in the anatomical place, and there is a mass in the umbilical region surrounded by dense adhesions. The adhesions were released and this mass discovered to be WS, splenectomy was done. Vaccination against pneumococci and Haemophilus influenza were given, and the patient discharged uneventfully on the fourth postoperative day. Asymptomatic WS could be found incidentally during surgery or during abdominal imaging for any reason. Furthermore, WS can present with an acute abdomen or recurrent abdominal pain. The only treatment is surgery even in asymptomatic cases because of the high possibility of complications. Splenopexy can be done if the spleen showed no torsion or splenomegaly or hypersplenism otherwise splenectomy is the second option.

Keywords: Ptosis, splenectomy and torsion, splenopexy, thrombocytosis, wandering spleen


How to cite this article:
Elhady HA, Abd-Elwahab ESM, Abd Elghany RA. Recurrent abdominal pain with thrombocytosis:A presentation of wandering spleen. Formos J Surg 2019;52:189-92

How to cite this URL:
Elhady HA, Abd-Elwahab ESM, Abd Elghany RA. Recurrent abdominal pain with thrombocytosis:A presentation of wandering spleen. Formos J Surg [serial online] 2019 [cited 2019 Nov 19];52:189-92. Available from: http://www.e-fjs.org/text.asp?2019/52/5/189/269927




  Introduction Top


A “wandering”' spleen, also known as floating, aberrant, or ptotic spleen, describes splenic position outside of its expected location in the left upper quadrant.[1] Wandering spleen (WS) is a rare occurrence, and the incidence is <0.2%.[2] The precise etiology is never completely understood due to the rarity of the condition.[3]

The ectopic spleen is mostly congenital and described in the pediatric population, typically between ages 3 months and 10 years. Acquired causes, on the other hand, include splenomegaly, trauma, ligamentous laxity, and hormonal secondary to pregnancy. Long pedicle torsion results in partial or complete splenic infarction.[3]

Clinical manifestations vary from asymptomatic to an abdominal emergency. The most common presentation in children is acute abdominal pain. Symptoms may remain limited or absent for long periods of time. Nevertheless, complications related to torsion or compression of abdominal organs are quite common and may cause progressive splenic infarction and necrosis of the pancreatic tail.[4]

Without detorsion, splenic infarction and gangrene ensue. Chronic torsion typically causes venous congestion and splenomegaly.[5]

Laboratory tests are usually nonspecific. Imaging procedures, such as sonography, nuclear scintigraphy, computed tomography (CT), and magnetic resonance, are the common diagnostic modalities. The absence of the spleen in the left hypochondrium and the presence of a soft-tissue mass resembling a spleen in the lower abdomen are highly suggestive of WS. Both abdominal sonography as the CT is usually accomplished to diagnose WS symptom.[4]

In children without splenic infarction, the therapeutic procedure of choice is splenopexy, suturing the spleen to the diaphragm, abdominal wall, or omentum.[5]

Thrombocytopenia in patients with WS has rarely been reported. Most reports do not mention the patients' platelet counts. When reported, platelet counts are typically either normal or elevated.[6]


  Case Report Top


A 15-year-old girl has been reported to our hospital complaining of repeated attacks of abdominal pain in the past month. The pain is felt at epigastrium and around the umbilicus. It was associated with vomiting. She received intravenous fluids, analgesics, and antispasmodics with some improvement.

Abdominal examination revealed a palpable mass of about 14 cm × 8 cm. The mass showed limited mobility and mild tenderness. It was dull on percussion. Throb space gives resonance note on percussion. Other systemic examinations were unremarkable. Complete blood count revealed platelets (790 × 103/mL), white blood cells (9,700 × 103/mL), and hemoglobin (8 g/dL); all other laboratory tests were normal.

Abdominal sonography and CT showed the empty left hypochondrium and enlarged spleen 17 cm in the long axis with no vascular or focal lesions [Figure 1].
Figure 1: Computed tomography scan showed the absence of the spleen in the upper sections of the abdomen

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Using a midline incision, abdominal exploration was done and revealed the spleen not in it is place, and there is a mass in the umbilical region surrounded by dense peritoneal adhesions [Figure 2]. The omentum and bowels were adherent [Figure 3] and [Figure 4]. The adhesions were released; the swelling was confirmed to be the spleen, and it was observed that the cause of pain and the adhesions were the previous attack of a patch of splenic infarction [Figure 5]. The splenic pedicle was long, and its arterial pulsations are hardly felt. Due to extensive adhesions and splenomegaly, it was not possible to do splenopexy, and splenectomy was done. The postoperative period passed uneventfully, and the patient discharged 4 days later. She consented for the anonymous reporting of his case. Such reporting was also approved by our local bioethical committee.
Figure 2: Spleen with thick peritoneal adhesions (arrow)

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Figure 3: Computed tomography scan showed an enlarged spleen adherent to the bowel (arrow heads)

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Figure 4: Spleen with omental adhesion (arrow)

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Figure 5: Spleen with patch of infarction (arrow)

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The study involves human study, but the IRB/IRC approval is exempt, because the case in this study is not subjected to any test, we only reported the findings.


  Discussion Top


WS is a rare clinical condition, with only about 500 cases reported worldwide.[7] The age at diagnosis ranged from 3 months to 82 years.[8]

CT is the modality of choice for diagnosing a WS when the torsion is suspected. CT findings include the ectopic position of the spleen, whorled appearance of the splenic pedicle, and surrounding fat at the splenic hilum, which may or may not be accompanied by twisting of the pancreatic tail. The spleen may be enlarged due to hypercongestion, and there may be a minimal or absent postcontrast enhancement of the splenic parenchyma, which is usually a sign of infarction.[9]

Prophylactic splenopexy is preferred even if asymptomatic as the risk of torsion is high. WS is also prone to injury due to its ectopic location unprotected by the rib cage and is another reason for prophylactic splenopexy.[10]

Detorsion and splenopexy is a reasonable surgical option, even in patients presenting with an acute abdomen, when there is no evidence of infarction, thrombosis, or hypersplenism. Splenic preservation is highly recommended in very young patients, those under 1 year of age up to those in the third decade of life due to risk for overwhelming postsplenectomy sepsis.[11]

After splenectomy, if it is not possible before surgery, it is mandatory to give prophylactic antibiotic therapy and vaccination for encapsulated bacteria to prevent postsplenectomy sepsis syndrome.[4]

Both surgeries can be done by laparotomy or laparoscopy, depending on the surgeon experience. Splenic surgery by laparoscopic approach is the preferred technique.[4]

The cause of extensive adhesions in our case found during the surgery [Figure 2] was interpreted as a result of perisplenitis due to the recurrent ischemic events resulting from splenic ptosis. Platelet count in cases diagnosed with WS is not reported in all studies. Thrombocytopenia may be as a result of sequestration in the enlarged spleen. Thrombocytosis in this reported case can be explained by impaired splenic perfusion for a long time, resulting in reactive thrombocytosis as a well-known sequel after splenectomy.


  Conclusion Top


WS is a condition can involve different age groups. Once diagnosed either symptomatizing or not should be treated surgically. Splenopexy and splenectomy are considered as options for treating. WS can present with abdominal pain and thrombocytosis.

Ethical approval

This study was approved by faculty of medicine for girls -IRB (FMG-IRB) of Al-Azhar University, approval no. 201910210 obtained on October 16th, 2019.

Declaration of patient consent

The authors certify that they have obtained all appropriate patient consent forms. In the form the patient(s) has/have given his/her/their consent for his/her/their images and other clinical information to be reported in the journal. The patients understand that their names and initials will not be published and due efforts will be made to conceal their identity, but anonymity cannot be guaranteed.

Financial support and sponsorship

Nil.

Conflicts of interest

There are no conflicts of interest.



 
  References Top

1.
Zhang P, Dyer RB, Holbert BL. A “wandering spleen”. Abdom Radiol (NY) 2018;43:2525-6.  Back to cited text no. 1
    
2.
Priyadarshi RN, Anand U, Kumar B, Prakash V. Torsion in wandering spleen: CT demonstration of whirl sign. Abdom Imaging 2013;38:835-8.  Back to cited text no. 2
    
3.
Hui Lian H, Hayati F, Ali AA, Azizan N, Che Ani MF, Suhaili MA, et al. Wandering spleen: A unique cause of acute abdomen. Folia Morphol (Warsz) 2018;77:400-2.  Back to cited text no. 3
    
4.
Viana C, Cristino H, Veiga C, Leão P. Splenic torsion, a challenging diagnosis: Case report and review of literature. Int J Surg Case Rep 2018;44:212-6.  Back to cited text no. 4
    
5.
Smoot RL, Truty MJ, Nagorney DM. Content s repository only. Splenectomy for conditions other than trauma. In: Yeo CJ, editor. Shackelford's Surgery of the Alimentary Tract. 8th ed., Vol. 2, Ch. 141. Philadelphia: Philadelphia, PA 19103-2899, Elsevier; 2019. p. 16353.  Back to cited text no. 5
    
6.
Moll S, Igelhart JD, Ortel TL. Thrombocytopenia in association with a wandering spleen. Am J Hematol 1996;53:259-63.  Back to cited text no. 6
    
7.
Puranik AK, Mehra R, Chauhan S, Pandey R. Wandering spleen: A surgical enigma. Gastroenterol Rep (Oxf) 2017;5:241-3.  Back to cited text no. 7
    
8.
Magowska A. Wandering spleen: A medical enigma, its natural history and rationalization. World J Surg 2013;37:545-50.  Back to cited text no. 8
    
9.
Khan DB, Khandwala K, Abbasi SU, Khan SD, Raza R. Torsion of wandering spleen with infarction. Cureus 2018;10:e3177.  Back to cited text no. 9
    
10.
Thambidorai CR, Imtiaz A, Nafiqudin M. Torsion of a wandering spleen with whorled appearance of the splenic hilum in CT scan. Med J Malaysia 2005;60:653-4.  Back to cited text no. 10
    
11.
Bouassida M, Sassi S, Chtourou MF, Bennani N, Baccari S, Chebbi F, et al. A wandering spleen presenting as a hypogastric mass: Case report. Pan Afr Med J 2012;11:31.  Back to cited text no. 11
    


    Figures

  [Figure 1], [Figure 2], [Figure 3], [Figure 4], [Figure 5]



 

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