Splenetic Torsion on Ectopic Spleen: a Case Report

Splenic volvulus, a rare torsion of the spleen around its vascular axis, can lead to severe tissue necrosis without prompt treatment. Underlying anatomical factors such as elongation of the splenic pedicle and ligament laxity increase the risk of torsion. Diagnosis is often made during emergency surgical intervention due to the rarity of the condition and the lack of specificity of symptoms. A 30-year-old woman presented with acute abdominal symptoms accompanied by fever, leading to emergency laparotomy revealing splenic volvulus. Imaging, particularly computed tomography, plays a crucial role in diagnosis. Treatment typically involves splenectomy in cases of necrosis. Wandering spleen, usually caused by ligament hyperlaxity, is a rare but important entity to recognize, often requiring surgical intervention to prevent serious complications.


Introduction
Splenic volvulus on a mobile spleen is a rare phenomenon characterized by the torsion of the spleen around its vascular axis [1,2].This torsion leads to an interrup�on of blood flow to the spleen, poten�ally resul�ng in �ssue necrosis and serious complica�ons if not promptly treated [3].O�en, this condi�on is atributed to underlying anatomical factors, primarily a congenital malforma�on of the spleen's fixa�on system [4,5].Elonga�on of the splenic pedicle is one of the main predisposing factors to splenic torsion [6].This pedicle consists of blood vessels and suppor�ng structures that hold the spleen in place within the abdominal cavity [7].When this pedicle is abnormally long, it grants more mobility to the spleen, thereby increasing the risk of torsion.This condi�on may be present from birth, resul�ng from an anomaly in embryonic development [8].In addi�on to pedicle elonga�on, other anatomical factors may also play a role in the development of splenic volvulus.Ligament laxity, which normally fixes the spleen in its anatomical posi�on, is o�en observed.In some pa�ents, par�al or complete agenesis of these ligaments may allow the spleen to move more freely within the abdominal cavity, thus increasing the risk of torsion [9].Due to its rarity and the lack of specificity of symptoms, the diagnosis of splenic volvulus is o�en made during emergency surgical interven�on, as in the case we report of a splenic volvulus operated on as an emergency in a fas�ng woman.Observation A 30-year-old woman presented to the emergency department with a febrile abdominal pain syndrome evolving for 48 hours.Her medical history revealed psychiatric follow-up but no surgical history.Ini�al clinical examina�on showed a preserved general condi�on but with hyperthermia at 39.2°C.Addi�onally, a mobile and tender mass was palpated in the right 137 hypochondrium, extending beyond the midline.Blood tests revealed anemia with a hemoglobin level of 9.5 g/dL and a white blood cell count of 8500/mm³.Radiological examina�ons were then performed to evaluate the cause of abdominal pain.Abdominal ultrasound iden�fied a hypoechoic forma�on in the right flank and hypochondrium, measuring 160 mm by 100 mm, with echoes sugges�ve of an infected mesenteric cyst (Figure 1).Furthermore, moderate ascites was observed.Abdominal computed tomography confirmed the presence of a mixed-density forma�on, enhancing a�er contrast injec�on, measuring 153.5 mm by 88.4 mm.This forma�on was located in the right hypochondrium and flank, intraperitoneal, and accompanied by low-abundance ascites (Figure 2).with areas of infarc�on scatered throughout was observed, twis�ng around its vascular axis with two turns (Figure 3).Absence of ligamentous atachment and a thrombosed splenic pedicle measuring 8 cm long were noted (Figure 4).Splenectomy was performed, accompanied by drainage of the peritoneal cavity and postopera�ve an�bio�c therapy.Postopera�ve follow-up was uneven�ul, and the pa�ent was referred to a hematology service for pneumococcal vaccina�on.Anatomopathological results confirmed splenic infarc�on without specific lesions.

Discussion
The wandering spleen, first described in 1792 by Riolan, is a rare but clinically significant anatomical en�ty.Its prevalence is low, es�mated at around 0.5%, and it is more common in children and young women, although a female predominance is observed in adults.This condi�on is generally caused by ligament hyperlaxity or agenesis, which normally fixes the spleen, resul�ng from either a congenital anomaly or an acquired cause.

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In the case of congenital form, a failure of posterior mesogastrium fusion leads to elonga�on of the splenic pedicle, allowing the spleen to move freely within the abdominal cavity.Acquired risk factors include gastric distension, splenomegaly, abdominal trauma, and pregnancy.Symptoms of the wandering spleen can vary, ranging from asymptoma�c to intermitent abdominal pain due to spontaneous torsions and detorsions of the spleen.In chronic cases, torsion of the splenic pedicle can lead to splenomegaly, hypersplenism, and eventually splenic infarc�on with peri-splenic adhesions, resul�ng in chronic abdominal pain.When splenic torsion occurs, it can lead to acute surgical abdomen, characterized by severe abdominal pain, nausea, vomi�ng, and some�mes fever.Physical examina�on may reveal peritoneal signs, and palpa�on may reveal an abdominal or pelvic mass, as observed in our pa�ent.Imaging plays a crucial role in the diagnosis of the wandering spleen.Abdominal ultrasound is o�en used as the ini�al imaging modality, allowing visualiza�on of an abdominal mass and the absence of the spleen in its normal loca�on.Lack of Doppler vasculariza�on can also confirm the diagnosis.However, in some cases, computed tomography (CT) may be necessary, par�cularly in the presence of limita�ons to ultrasound such as ileus, obesity, or hypertrophy of the le� lobe of the liver.CT is considered the imaging modality of choice for diagnosing the wandering spleen, allowing visualiza�on of the whirl sign of the splenic pedicle and signs of splenic infarc�on.Once the diagnosis is confirmed, surgical interven�on is generally necessary.In the absence of splenic necrosis, splenopexy may be performed to fix the spleen in its normal anatomical posi�on.However, in cases of necrosis, splenectomy is o�en required.

Conclusion
Wandering spleen is a rare but important phenomenon to consider in the presence of recurrent symptoms such as acute abdominal pain, painful splenomegaly, or pelvic mass, especially when clinical examina�on and blood test results are inconclusive.Resor�ng to a CT scan is essen�al to confirm the diagnosis, exclude other diagnoses, detect possible serious complica�ons such as splenic torsion with infarc�on, and guide treatment choice.In most cases, splenopexy is preferred, but splenectomy may be necessary in the presence of signs of infarc�on.
Mazouzi C, Blik N, Laraba N. Splenetic Torsion on Ectopic Spleen: a Case Report.Eur J Med Health Res, 2023;1(2):136-8.DOI: 10.59324/ejmhr.2023.1(2reproduction in any medium, on the condition that users give exact credit to the original author(s) and the source, provide a link to the Creative Commons license, and indicate if they made any changes.

Figure 1 :Figure 2 :
Figure 1: Ultrasound Appearance of the Spleen