DOI: 10.7860/JCDR/2015/13135.

6541
Case Report

Ectopic Spleen Presenting as Lump

Surgery Section
Abdomen: A Rare Case Report and
Review of Literature
BAPURAPU RAJARAM1, MADIPEDDI VENKANNA2, DODDA RAMESH KUMAR3,
BODA KUMARASWAMY4, BACHANNAGARI SRINIVAS REDDY5

ABSTRACT
Ectopic spleen is due to failure of fusion of the mesogastrium and the lining body wall epithelium, resulting in lax or absent supporting
ligaments of spleen, making it abnormally mobile. This case presented as lump abdomen with history of recurrent attacks of abdominal
pain. Clinical diagnosis was unidentified abdominal mass. The radiological imaging was suggestive of the diagnosis, and the exploration
of abdomen has clinched the diagnosis.

Keywords: Mobile spleen, Torsion of spleen, Unidentified abdominal mass

case report Adhesions were released, spleen was derotated. The surface of the
A 24-year-old woman presented to the out-patient Department spleen has shown clear infarcted area even after derotation. Hence
of General Surgery, Kakatiya Medical College/Mahatma Gandhi splenectomy was done [Table/Fig-3]. The postoperative course was
Memorial Hospital, Warangal, Telangana state, India with complaint uneventful. Patient was given vaccines. Patient was discharged
of lump abdomen and chronic intermittent pain abdomen. On after recovery.
physical examination, her vital signs were within normal limits. There
was no history of bowel or urinary symptoms. Patient underwent Discussion
two times caesarean section. Examination of the abdomen revealed Ectopic spleen is a rare entity. The incidence of torsion is estimated
a freely mobile intra abdominal mass in right lumbar, right iliac fossa to be less than 0.2% [1]. Incidence is higher among multiparous
and umbilical regions [Table/Fig-1]. woman [2]. Most cases are diagnosed in adults aged between 20 to
On abdominal ultrasonography (USG), the spleen was not found to 40 years [2]. So far, about 500 cases have been reported [1].
be in its normal anatomic position, and bowel loops were observed The clinical presentation of an ectopic spleen is variable. Affected
in the left upper quadrant of the abdomen with normal position of patients may be asymptomatic and this condition may be incidentally
kidneys and ovaries. An enlarged spleen extending to the pelvis discovered on physical examination, or on imaging studies
from right lumbar region with large hypoechoic area was noted. No performed for other unrelated reasons, as an abdominal or pelvic
blood flow in the splenic artery and vein was observed on Doppler mass that may or may not be accompanied by gastrointestinal or
USG. On abdominal intravenous contrast-enhanced computed urinary symptoms [3-5]. Differential diagnosis includes adenopathy,
tomography (CT) scan, the spleen was not seen in its normal lymphoma, extramedullary haematopoeisis. The patient may become
anatomic position, but rather was located in right lumbar region, symptomatic due to abnormal mobility, torsion and compromised
extending to the right adnexal region. The splenic parenchyma blood supply. Patients may have mild, intermittent abdominal pain
showed a non-homogeneous enhancing area suggestive of due to splenic congestion with intermittent torsion and spontaneous
infarction [Table/Fig-2a,b]. Complete blood picture was normal. derotation, as well as splenomegaly as a result of vascular
Based on physical examination USG and CT findings, a laparotomy congestion [4,5]. Patients may present with an acute abdomen
through a midline vertical incision was performed. It was due to torsion of the splenic pedicle with subsequent infarction [2].
intraoperatively noted that the spleen lacked its normal ligamentous Differential diagnosis includes acute appendicitis, ovarian torsion,
attachments and was suspended only by an elongated vascular cholecystitis. The splenic torsion is sometimes associated with
pedicle in right lumbar, umbilical and right iliac fossa regions gastric or pancreatic tail volvulus. The intestinal obstruction by
with adhesions to liver and bowel loops. The pedicle of spleen splenic flexure volvulus is the only colonic manifestation reported
was twisted two times (720 degrees). There was mild free fluid [6]. In the present case, patient presented with lump abdomen
in abdomen; the left hypochondrium was filled with bowel loops. associated with chronic intermittent pain abdomen.

[Table/Fig-1]: Clinical photograph demonstrating lump in right lumbar, umbilical and right iliac fossa regions, [Table/Fig-2a]: Coronal and sagittal sections of computed axial
tomography scan showing spleen in right lumbar, right iliac fossa, umbilical regions with non enhancing areas suggestive of infarction
[Table/Fig-2b]: Axial computed tomography scan showing an ectopic spleen (S) in right lumbar region and umbilical regions

26 Journal of Clinical and Diagnostic Research. 2015 Sep, Vol-9(9): PD26-PD27

www.jcdr.net B.Rajaram. M.S. et al., An Ectopic Spleen Presenting as Lump Abdomen: Report of A Rare Case and Review of Literature

depending on the viability of the spleen. Preservation of the spleen

by different surgical techniques has been the focus of modern
therapeutic concepts for the treatment of ectopic spleen [3,7]. In
present case splenectomy was done because of infarction. Most
authors now support the use of splenectomy if there is torsion,
splenic vein thrombosis, splenic infarction and hypersplenism.
Conversely, splenopexy is preferred when a viable ectopic spleen is
found at laparotomy [3]. Splenopexy by means of the extraperitoneal
pocket creation appears to allow anatomic placement of the spleen
along with the protection of the rib cage without the employment of
biomaterials [6]. Presently, splenic surgery by laparoscopic approach
is an extensively used and a preferred technique because it is less
painful and allows for better cosmesis, early ambulation, overall less
morbidity, and a faster return to work. The methods include creating a
pouch in the omentum, stomach, or colon and the use of absorbable
mesh to fix the spleen in its normal anatomical location [8].

Conclusion
Ectopic spleen, with or without torsion is a rare clinical entity. Imaging
modalities play an important role in the diagnosis. Early diagnosis
and treatment of an ectopic spleen may reduce the frequency of
splenectomy. Therefore, if there is no spleen at the normal anatomic
location by imaging studies, one should consider the possibility of
an ectopic spleen in patients who present with palpable abdominal
mass, with or without pain abdomen.

[Table/Fig-3]: Intraoperative findings of torsion and infarction of spleen References

[1] Sharma A, Salerno G. A torted wandering spleen: a case report. J Med Case
Rep. 2014;8:133.
In general, laboratory tests are usually non-specific; however, they [2] Maksoud SF, Swamy N, Khater NH. Tale of a wandering spleen: 180 degree
may occasionally reveal pancytopenia as evidence of hypersplenism torsion with infracted spleen and secondary involvement of liver. J Radiol Case
or functional asplenia, by evaluating peripheral smear for Howell- Rep. 2014;8(6):18-26.
[3] Cho SA, Choh NA, Dar I, Jehangir M, Yousuf R. Wandering spleen
Jolly bodies or other particles [4]. In the present case complete
presenting as recurrent abdominal pain in a young female. Indian J Pediatr.
blood picture was normal. 2008;75(11):1182.
To detect a suspected ectopic spleen with torsion, various [4] Feroci F, Miranda E, Moraldi L, Moretti R. The torsion of a wandering pelvic
spleen: a case report. Cases J. 2008;1(1):149.
diagnostic modalities can be used: Technitium–99m sulphur colloid [5] Misawa T, Yoshida K, Shiba H, Kobayashi S, Yanaga K. Wandering spleen with
scintigraphy, Ultrasonography, Doppler ultrasonography, CT scans, chronic torsion. Am J Surg. 2008;195(4):504-05.
CT angiography and MRI [3-5]. In present case Ultrasonography, [6] El Bouhaddouti H, Lamrani J, Louchi A, El Yousfi M, Aqodad N, Ibrahimi A, et
Doppler ultrasonography and CECT Abdomen were performed to al. Torsion of a wandering spleen. Saudi J Gastroenterol. 2010;16(4):288–91.
[7] Soleimani M, Mehrabi A, Kashfi A, Fonouni H, Buchler MW, Kraus TW. Surgical
diagnose the condition. treatment of patient with wandering spleen: report of six cases with a review of
Historically, splenectomy has been the treatment for symptomatic the literature. Surg Today. 2007;37 (3); 261-69.
[8] Faridi MS, Kumar A, Inam L, Shahid R. Wandering spleen- a diagnostic challenge:
ectopic spleen [4]. Now the treatment is splenopexy or splenectomy case report and review of literature. Malays J Med Sci. 2014;21(6):57-60.

PARTICULARS OF CONTRIBUTORS:
1. Associate Professor, Department of General Surgery, Kakatiya Medical College/ Mahatma Gandhi Memorial Hospital, Warangal, Telangana, India.
2. Assistant Professor, Department of General Surgery, Kakatiya Medical College/ Mahatma Gandhi Memorial Hospital, Warangal, Telangana, India.
3. Professor, Department of General Surgery, Kakatiya Medical College/ Mahatma Gandhi Memorial Hospital, Warangal, Telangana, India.
4. Assistant Professor, Department of General Surgery, Kakatiya Medical College/ Mahatma Gandhi Memorial Hospital, Warangal, Telangana, India.
5. Junior Resident, Department of General Surgery, Kakatiya Medical College/ Mahatma Gandhi Memorial Hospital, Warangal, Telangana, India.

NAME, ADDRESS, E-MAIL ID OF THE CORRESPONDING AUTHOR:

Dr. B. Rajaram,
2-2-23/B2, Heritage Residency, Behind Rang Restaurant, Nayeem Nagar, Vidyaranyapuri,
Hanamkonda, Warangal, Telangana - 506001, India. Date of Submission: Jan 27, 2015
E-mail : paulrajaram@yahoo.com Date of Peer Review: May 04, 2015
Date of Acceptance: Aug 03, 2015
Financial OR OTHER COMPETING INTERESTS: None. Date of Publishing: Sep 01, 2015

Journal of Clinical and Diagnostic Research. 2015 Sep, Vol-9(9): PD26-PD27 27