Case notes

A 23-year-old nulliparous woman, at 12 weeks’ twin gestation, presented to the emergency department with a 3-day history of intractable vomiting. This had increased in intensity and frequency overnight and was associated with shifting abdominal pain. Physical examination showed diffuse abdominal tenderness and a palpable left lower-quadrant mass. Her platelet count was 70 × 10 ³ /mm ³ . Otherwise, the complete blood cell count and differential were normal, as were liver function and pancreatic enzyme levels.

Ultrasonography of the abdomen revealed a 20-cm spleen. Magnetic resonance imaging confirmed splenomegaly with evidence of whirling of the splenic pedicle. Emergency laparotomy showed significant twisting of the splenic artery and vein with infarction ( Figure ). Splenectomy was performed.

Intraoperative image shows spleen and twisting of splenic artery and vein.

Ghazeeri. The wanderer. Am J Obstet Gynecol 2010.

Conclusions

Wandering spleen, a rare clinical radiologic entity, might be congenital or acquired. It is characterized by splenic hypermobility resulting from failed fusion of the dorsal peritoneum or abnormal development of the splenic peritoneal attachments—the gastrosplenic, splenorenal, and phrenicocolic ligaments. Laxity of these ligaments, as occurs in muscular dystrophies or pregnancy, can liberate the spleen from its normal posterolateral position in the left upper quadrant, making it an intraperitoneal hypermobile organ, especially in the presence of splenomegaly. Torsion of the spleen’s long vascular pedicle becomes a risk.

The condition is more often seen in young multiparas. Potential predisposing factors in this patient population include hormonal effects and abdominal laxity. Patients may be completely asymptomatic, have a movable mass in the abdomen, or present with acute, chronic, or intermittent symptoms due to torsion. Early clinical diagnosis may be difficult, particularly in pregnancy, so imaging modalities play an important role.

When women present with abdominal pain and a palpable mass during pregnancy, wandering spleen should be included in the differential diagnosis. Our patient’s postoperative course was smooth. However, at 20 weeks’ gestation, her pregnancy was complicated by bleeding due to placenta previa, which necessitated admission and transfusion. She was discharged at 24 weeks but readmitted at 33 weeks with preterm premature rupture of the membranes. At that point, she had a cesarean delivery.