Downloaded from www.ajronline.org by 109.161.198.5 on 08/29/15 from IP address 109.161.198.5. Copyright ARRS. For personal use only; all rights reserved
307
Case Report
Acute Torsion of a Wandering Spleen: Diagnosis Duplex Doppler and Color Flow Sonography A. Nemcek,
Albert
Jr.,1 Frank
H. Miller,
and Steven
W. Fitzgerald
The spleen is typically held in a relatively fixed position in the left upper quadrant by suspensory ligaments derived from
in the extremities
and neck.
level
(which
the dorsal mesogastrium and by the pressure exerted by surrounding organs and musculature. The term wandering spleen is commonly applied to a splenic hypermobility that results from laxity or maldevelopment of its suspensory ligaments. Other acquired and congenital factors may accentuate
a WBC
this tendency.
A wandering
spleen
is at risk for torsion
of 12.i
count
silhouette
CT
obtained
scans
of its
limb girdle muscular
constant
left lower
and low-grade fever. Three years before admission, developed that required resection of the descending tomy.
Since
attributed imaging
studies,
Physical mild
surgery, and Her
sounds.
abdomen, patient
related in the past.
I
geneous
spleen
with
previous
the
hilar
were
that
she
She
had
felt
had diffuse
22, 1 991
Department
;
this
accepted
of Diagnostic
of flow
the spleen,
with
mass
hypoactive
shifting
position
after revision Radiology, reprint
most March
1991 0361 -803X/91/1572-0307
the
other
of abdominal
episodes
mass. Multiple pain
was
obtained
diverticulitis had enlarged was
Evidence
noted
Color
on
flow
the
present
admission
(Fig. 1 D). It showed an inhomoand changed position compared also. and
of
Torsion duplex
with 3.5- and 7.0-MHz
acutely and
thrombosed ischemia
Doppler
were
sonographic
imaging
transducers
View, CA) (Fig. iE). The spleen lay very close to
in both
small
vessels
of the
abdominal
wall
imme-
Doppler
sonography
revealed
no detectable
flow.
The findings were considered diagnostic of splenic infarction due to torsion. Doppler examination of the main splenic artery just distal to the celiac artery showed antegrade flow with low diastolic velocity
main splenic vein normal hepatopetal
intermitpronounced
bow-impedartery. The
behind the pancreas was patent and showed a direction of flow. A S9mTc..sulfur colboid scan was
1 2, 1991.
Northwestem
requests
quadrant.
and a high resistive index of 84%, while a characteristic ance flow pattern was shown in the common hepatic
in the left mid to upper
atrophy,
in the left upper
to the spleen and abdominopelvic vessels deep to thorough interrogation of the splenic substance with color
flow and duplex
distended
count.
superficial
with
muscular
IL 6061 1. Address
August
diately
pain
mildly
scan
performed
Mountain
abdominal
to palpation
for
examinations.
vessels
suspected.
detection
treated presumptively with antibiotics. revealed a cachectic-appearing woman in was
that
that was well documented
a firm, large mass was felt. On questioning,
Ct., Chicago,
AJR 157:307-309,
diverticulitis had colon and cobs-
lower
platelet
the left anterior abdominopelvic wall and was easily visualized in its entirety. The splenic parenchyma was diffusely abnormal. Despite
pain
been
abdomen
January
All authors:
Fairbanks
had
She was tender
where
tently
Received
diverticulitis
examination
distress.
bowel
she had had intermittent
to recurrent
CT
of suspected
splenic
dystro-
quadrant
a hemoglobin
3 days to 9.2 g/dl),
next
and a normal
previously
An unenhanced
(Acuson, of intense,
included
the
showed a large pelvic soft-tissue
was identified
because
studies
history
values
over
had demonstrated the spleen in a number of different positions (Figs. 1A-iC). Some of the CT examinations had been performed without enhancement because of a prior allergic reaction to contrast material. The ectopic location of splenic tissue suggested by the CT scans had been confirmed with “Tc-suIfur colboid scanning.
Case Report woman with suspected
Laboratory
decreased
of 27,000/mm3,
No splenic
strongly
A 42-year-old
g/dl
A plain film of the abdomen
vascular pedicle. We report a case of torsion of a wandering spleen in which the preoperative diagnosis was made based on serial CT scans and duplex Doppler and color flow sonography with confirmation by 99mTcsuIfur colloid scans. To our knowledge this is the first case in which duplex and color flow Doppler findings in this entity have been reported.
phy had a i-day
by CT and
University
to A. A. Nemcek, C American
Medical
School
and
Northwestern
Memorial
Hospital,
Olson
Pavilion,
710
N.
Jr.
Roentgen
Ray Society
/
NEMCEK
Downloaded from www.ajronline.org by 109.161.198.5 on 08/29/15 from IP address 109.161.198.5. Copyright ARRS. For personal use only; all rights reserved
308
ET AL.
AJR:157,
August
1991
Fig. 1.-A-D, CT scans obtained 35 months (A), 28 months (B), and 2 months (C) before admission and on day of admission (D). Changes in splenic position and hilar orientation are noted on each scan. In D, spleen has enlarged and shows inhomogeneous parenchymal attenuation. Orientation of splenic hilus has shifted 180#{176} as compared with prior examination. Tortuous, high-density structures (arrow) in splenic hilar region on this unenhanced scan are consistent with acutely thrombosed vessels. E, 3.5-MHz sector sonogram of left lower quadrant, with simultaneous color flow evaluation. Spleen (white arrow) is inhomogeneous and predominantiy hypoechoic. Evidence of flow is present in abdominopelvic vessels deep to spleen (black arrow) but not within splenic parenchyma. Similar examination (not shown) of superficial subcutaneous tissues and immediately subjacent splenic tissue with a 7.0-MHz linear-array transducer revealed flow in small subcutaneous vessels, but again no splenic parenchymal
also
obtained.
mulation
It confirmed
in the
liver
but
infarction not
the
by showing
radionuclide
asymptomatic
accu-
spleen.
from
Laparotomy revealed torsion of a freely mobile spleen attached only at its hilum by a long pedicle to other abdominal structures. The spleen had rotated about its axis several times and appeared congested. The distal pancreas and bowel were not incorporated into
the torqued splenic
segment.
Torsion
of the splenic pedicle had resulted
in
venous
and arterial thrombosis. Surgical pathology revealed infarction of a spleen weighing 989 g; a subcapsular also was noted. The clinical course after splenectomy was
hemorrhagic
hematoma
abdominal
torsion; may
to an acute abdominal
torsion
and infarction
have
crisis resulting
[3]. Intermittent
pain may result from chronic
we speculate
and detorsion
verticulitis,
that in this case spontaneous
of the splenic been
and
mild or
the cause
pedicle,
rather
of some
than di-
of the other
episodes of abdominal pain. A number of reports and reviews have dealt with the various radiobogic manifestations of wandering spleen [1 , 4-8]. Re-
ings
Congenital spleen
maldevebopment most
likely
of the suspensory
precedes
the
majority
its vascular
pedicle.
abdominal
previous
In the
present
case,
for
surgery
most
likely
with abdominal
masses
and pain. Find-
on both
imaging methods have included of an abdominal or pelvic soft-tissue mass
demonand ab-
of
stration
of cases
of
sence of the spleen in its typical location in the left upper quadrant [i , 4-8]. Previous radiographs may have demonstrated the spleen in a normal location. As in this case, serial
example,
wall laxity due to severe muscular
abdominal
of patients
noted
ligaments
wandering spleen [i , 2]. However, other congenital and acquired conditions may accentuate the tendency of the spleen to migrate about the abdomen and pelvis and to rotate around
and
recurrent
evaluation
Discussion
creased
less severe torsion
patient splenic
cent reports of this entity have included findings on sonography or CT, reflecting increased use of these methods in the
uneventful.
the
acute
flow.
in-
atrophy
contributed
to
splenic torsion. The clinical presentation of wandering spleen ranges from the incidental finding of an abdominal mass in an
studies may show a shifting position of the spleen and its hilum [8]. If infarction of the spleen occurs, part or all of the
spleen will fail to enhance sonography
genicity
the
normal
of the spleen
appearance
with IV contrast homogeneous,
may
[8]. Complications
be replaced
associated
material
on CT; on
medium-level
echo-
by a heterogeneous
with torsion,
such
ACUTE
Downloaded from www.ajronline.org by 109.161.198.5 on 08/29/15 from IP address 109.161.198.5. Copyright ARRS. For personal use only; all rights reserved
AJR:157, August 1991
TORSION
OF WANDERING
SPLEEN
309
as involvement of the pancreatic tail, have been diagnosed on both sonography and CT [5, 8]. The use of color flow and duplex Doppler sonography allows evaluation of organ blood flow. In the present case, no flow could be detected in the splenic parenchyma, consistent with infarction. The lack of any detectable flow in the splenic parenchyma could be blamed on lack of sufficient Doppler sensitivity to slow or low-amplitude flow, but this seems
of wandering spleen had already been made. If this diagnosis is not suspected before signs and symptoms of torsion with infarction occur, we suspect that CT may most often suggest the specific diagnosis: sonography may be limited by bowel gas or body habitus in some patients, and nonvisualization of
unlikely because of the very superficial in this patient and our ability to detect
frequently subjects the patient to small but definable risks of contrast reaction. Sonography is used frequently as the initial
location of the spleen flow both immediately
superficial and deep to the torqued organ. The finding of a high resistive index in the splenic artery deserves comment. Assessment of vascular impedance with a variety of calculations relating to Doppler spectra has received a great deal of attention in the assessment of normal physiology as well as abnormality in certain organs, such as the transplanted kidney. However, little has been published regarding assessment of normal and pathologic splenic arterial impedance. In one study, Nakamura et al. [9] investigated the pulsatility index in splenic, hepatic, and superior mesenteric arteries in fasting subjects and found a significantly lower pulsatility index (and thus lower vascular impedance) in the splenic artery as compared with the superior mesenteric artery. Whether the range of measurements of vascular impedance in the normal splenic artery will permit differentiation from certain pathologic states is an area we believe deserves further investigation; our own limited investigation since the appearance disclosed no instances in which a normal
of this case splenic artery
has has
shown a resistive index of over 80%. At first appraisal, the surgical finding of several rotations of the spleen about its axis and the finding of any flow in the main splenic artery and vein seem discrepant. We offer what we believe is a tenable explanation: Branches of the main splenic artery (short gastric and pancreatic arteries) may remain patent proximal to the site of torsion of the long splenic vascular pedicle characteristic of this disorder. This would allow some antegrade flow through the proximal splenic artery despite increased impedance caused by acute occlusion of the major portion of the splenic arterial bed. Similarly, the presence of a normal direction of blood flow in the main splenic vein most likely relates to continued patency of splenic vein tributaries that join the main spelnic vein beyond the point
of torsion;
such
tributaries
could
include
the
inferior
meSentenc vein or varices that have formed as a result of chronic venous congestion. We anticipate that the pattems of flow in these major vessels could change depending on the exact site of torsion. We believe that the diagnosis of torsion in this case could have been made confidently if CT, sonography, or scintigraphy had been the first test. However, the preliminary diagnosis
the spleen
on scintigraphy
is nonspecific
and
On the other hand, CT is relatively
expensive
sonography,
to
imaging
exposes
the
test in patients
with
patient
nonlocalizing.
compared
with
radiation,
and
ionizing
abdominal
pain; we believe
that
as long as visualization of a torqued spleen is not impaired, the combination of sonography with duplex Doppler and color flow evaluation should allow confident diagnosis of this condition. Confirmatory findings would include absence of the spleen in its normal location and demonstration of a mass elsewhere in the abdomen or pelvis; lack of demonstrable flow within the splenic parenchyma, both on the color flow survey and directed search with duplex Doppler; and possible alterations in main splenic arterial flow, specifically, elevation of the resistive index or other measures of vascular impedance. In summary, we have reported a case of torsion of a wandering spleen for which there is correlative imaging by CT, sonography, and radionuclide scanning. To our knowledge, this is also the first reported case in which duplex Doppler and color flow sonography were used in the diagnostic evaluation
because
splenic parenchymal
of their ability
to noninvasively
evaluate
flow and flow in major splenic vessels.
REFERENCES 1 . Dodds WJ, Taylor imaging of splenic
AJ, Erickson SJ, Stewart ET, Lawson TL. Radiologic anomalies. AJR 1990;155:805-810 2. Woodward OAK. Torsion of the spleen. Am J Surg 1967;1 14:953-955 3. Abell I. Wandering spleen with torsion of the pedicle. Ann Surg 1933:98:722-725
4. Dachman AH. Anomalies
and congenital disorders. In: Friedman AC, ed. Radiology of the liver, bi!iary tract, pancreas and spleen. Baltimore: Wilhams & Wilkins, 1987:917-930 5. Parker LA, Mittelstaedt CA, Mauro MA, Mandell VS, Jacques PF. Torsion of a wandering spleen: CT appearance. J Comput Assist Tomogr 1984;8: 1201 -1204 6. Herman TE, Siegel MJ. CT of acute splenic wandering spleen. AJR 1991;1 56:151-153
torsion
in children
with
7. Kinori I, Rifkin MD. A truly wandering spleen. J Ultrasound Med 1988;7: 101 -1 05 8. Sheflin JR, Lee CM, Kretchmar KA. Torsion of wandering spleen and distal pancreas. AiR 1984:142:100-101 9. Nakamura T, Moriyasu F, Ban N, et al. Quantitative measurement of abdominal arterial flow using image-directed Doppler ultrasonography: superior mesenteric, splenic, and common hepatic arterial blood flow in normal adults. JCU 1989;17:261-268
307
Case Report
Acute Torsion of a Wandering Spleen: Diagnosis Duplex Doppler and Color Flow Sonography A. Nemcek,
Albert
Jr.,1 Frank
H. Miller,
and Steven
W. Fitzgerald
The spleen is typically held in a relatively fixed position in the left upper quadrant by suspensory ligaments derived from
in the extremities
and neck.
level
(which
the dorsal mesogastrium and by the pressure exerted by surrounding organs and musculature. The term wandering spleen is commonly applied to a splenic hypermobility that results from laxity or maldevelopment of its suspensory ligaments. Other acquired and congenital factors may accentuate
a WBC
this tendency.
A wandering
spleen
is at risk for torsion
of 12.i
count
silhouette
CT
obtained
scans
of its
limb girdle muscular
constant
left lower
and low-grade fever. Three years before admission, developed that required resection of the descending tomy.
Since
attributed imaging
studies,
Physical mild
surgery, and Her
sounds.
abdomen, patient
related in the past.
I
geneous
spleen
with
previous
the
hilar
were
that
she
She
had
felt
had diffuse
22, 1 991
Department
;
this
accepted
of Diagnostic
of flow
the spleen,
with
mass
hypoactive
shifting
position
after revision Radiology, reprint
most March
1991 0361 -803X/91/1572-0307
the
other
of abdominal
episodes
mass. Multiple pain
was
obtained
diverticulitis had enlarged was
Evidence
noted
Color
on
flow
the
present
admission
(Fig. 1 D). It showed an inhomoand changed position compared also. and
of
Torsion duplex
with 3.5- and 7.0-MHz
acutely and
thrombosed ischemia
Doppler
were
sonographic
imaging
transducers
View, CA) (Fig. iE). The spleen lay very close to
in both
small
vessels
of the
abdominal
wall
imme-
Doppler
sonography
revealed
no detectable
flow.
The findings were considered diagnostic of splenic infarction due to torsion. Doppler examination of the main splenic artery just distal to the celiac artery showed antegrade flow with low diastolic velocity
main splenic vein normal hepatopetal
intermitpronounced
bow-impedartery. The
behind the pancreas was patent and showed a direction of flow. A S9mTc..sulfur colboid scan was
1 2, 1991.
Northwestem
requests
quadrant.
and a high resistive index of 84%, while a characteristic ance flow pattern was shown in the common hepatic
in the left mid to upper
atrophy,
in the left upper
to the spleen and abdominopelvic vessels deep to thorough interrogation of the splenic substance with color
flow and duplex
distended
count.
superficial
with
muscular
IL 6061 1. Address
August
diately
pain
mildly
scan
performed
Mountain
abdominal
to palpation
for
examinations.
vessels
suspected.
detection
treated presumptively with antibiotics. revealed a cachectic-appearing woman in was
that
that was well documented
a firm, large mass was felt. On questioning,
Ct., Chicago,
AJR 157:307-309,
diverticulitis had colon and cobs-
lower
platelet
the left anterior abdominopelvic wall and was easily visualized in its entirety. The splenic parenchyma was diffusely abnormal. Despite
pain
been
abdomen
January
All authors:
Fairbanks
had
She was tender
where
tently
Received
diverticulitis
examination
distress.
bowel
she had had intermittent
to recurrent
CT
of suspected
splenic
dystro-
quadrant
a hemoglobin
3 days to 9.2 g/dl),
next
and a normal
previously
An unenhanced
(Acuson, of intense,
included
the
showed a large pelvic soft-tissue
was identified
because
studies
history
values
over
had demonstrated the spleen in a number of different positions (Figs. 1A-iC). Some of the CT examinations had been performed without enhancement because of a prior allergic reaction to contrast material. The ectopic location of splenic tissue suggested by the CT scans had been confirmed with “Tc-suIfur colboid scanning.
Case Report woman with suspected
Laboratory
decreased
of 27,000/mm3,
No splenic
strongly
A 42-year-old
g/dl
A plain film of the abdomen
vascular pedicle. We report a case of torsion of a wandering spleen in which the preoperative diagnosis was made based on serial CT scans and duplex Doppler and color flow sonography with confirmation by 99mTcsuIfur colloid scans. To our knowledge this is the first case in which duplex and color flow Doppler findings in this entity have been reported.
phy had a i-day
by CT and
University
to A. A. Nemcek, C American
Medical
School
and
Northwestern
Memorial
Hospital,
Olson
Pavilion,
710
N.
Jr.
Roentgen
Ray Society
/
NEMCEK
Downloaded from www.ajronline.org by 109.161.198.5 on 08/29/15 from IP address 109.161.198.5. Copyright ARRS. For personal use only; all rights reserved
308
ET AL.
AJR:157,
August
1991
Fig. 1.-A-D, CT scans obtained 35 months (A), 28 months (B), and 2 months (C) before admission and on day of admission (D). Changes in splenic position and hilar orientation are noted on each scan. In D, spleen has enlarged and shows inhomogeneous parenchymal attenuation. Orientation of splenic hilus has shifted 180#{176} as compared with prior examination. Tortuous, high-density structures (arrow) in splenic hilar region on this unenhanced scan are consistent with acutely thrombosed vessels. E, 3.5-MHz sector sonogram of left lower quadrant, with simultaneous color flow evaluation. Spleen (white arrow) is inhomogeneous and predominantiy hypoechoic. Evidence of flow is present in abdominopelvic vessels deep to spleen (black arrow) but not within splenic parenchyma. Similar examination (not shown) of superficial subcutaneous tissues and immediately subjacent splenic tissue with a 7.0-MHz linear-array transducer revealed flow in small subcutaneous vessels, but again no splenic parenchymal
also
obtained.
mulation
It confirmed
in the
liver
but
infarction not
the
by showing
radionuclide
asymptomatic
accu-
spleen.
from
Laparotomy revealed torsion of a freely mobile spleen attached only at its hilum by a long pedicle to other abdominal structures. The spleen had rotated about its axis several times and appeared congested. The distal pancreas and bowel were not incorporated into
the torqued splenic
segment.
Torsion
of the splenic pedicle had resulted
in
venous
and arterial thrombosis. Surgical pathology revealed infarction of a spleen weighing 989 g; a subcapsular also was noted. The clinical course after splenectomy was
hemorrhagic
hematoma
abdominal
torsion; may
to an acute abdominal
torsion
and infarction
have
crisis resulting
[3]. Intermittent
pain may result from chronic
we speculate
and detorsion
verticulitis,
that in this case spontaneous
of the splenic been
and
mild or
the cause
pedicle,
rather
of some
than di-
of the other
episodes of abdominal pain. A number of reports and reviews have dealt with the various radiobogic manifestations of wandering spleen [1 , 4-8]. Re-
ings
Congenital spleen
maldevebopment most
likely
of the suspensory
precedes
the
majority
its vascular
pedicle.
abdominal
previous
In the
present
case,
for
surgery
most
likely
with abdominal
masses
and pain. Find-
on both
imaging methods have included of an abdominal or pelvic soft-tissue mass
demonand ab-
of
stration
of cases
of
sence of the spleen in its typical location in the left upper quadrant [i , 4-8]. Previous radiographs may have demonstrated the spleen in a normal location. As in this case, serial
example,
wall laxity due to severe muscular
abdominal
of patients
noted
ligaments
wandering spleen [i , 2]. However, other congenital and acquired conditions may accentuate the tendency of the spleen to migrate about the abdomen and pelvis and to rotate around
and
recurrent
evaluation
Discussion
creased
less severe torsion
patient splenic
cent reports of this entity have included findings on sonography or CT, reflecting increased use of these methods in the
uneventful.
the
acute
flow.
in-
atrophy
contributed
to
splenic torsion. The clinical presentation of wandering spleen ranges from the incidental finding of an abdominal mass in an
studies may show a shifting position of the spleen and its hilum [8]. If infarction of the spleen occurs, part or all of the
spleen will fail to enhance sonography
genicity
the
normal
of the spleen
appearance
with IV contrast homogeneous,
may
[8]. Complications
be replaced
associated
material
on CT; on
medium-level
echo-
by a heterogeneous
with torsion,
such
ACUTE
Downloaded from www.ajronline.org by 109.161.198.5 on 08/29/15 from IP address 109.161.198.5. Copyright ARRS. For personal use only; all rights reserved
AJR:157, August 1991
TORSION
OF WANDERING
SPLEEN
309
as involvement of the pancreatic tail, have been diagnosed on both sonography and CT [5, 8]. The use of color flow and duplex Doppler sonography allows evaluation of organ blood flow. In the present case, no flow could be detected in the splenic parenchyma, consistent with infarction. The lack of any detectable flow in the splenic parenchyma could be blamed on lack of sufficient Doppler sensitivity to slow or low-amplitude flow, but this seems
of wandering spleen had already been made. If this diagnosis is not suspected before signs and symptoms of torsion with infarction occur, we suspect that CT may most often suggest the specific diagnosis: sonography may be limited by bowel gas or body habitus in some patients, and nonvisualization of
unlikely because of the very superficial in this patient and our ability to detect
frequently subjects the patient to small but definable risks of contrast reaction. Sonography is used frequently as the initial
location of the spleen flow both immediately
superficial and deep to the torqued organ. The finding of a high resistive index in the splenic artery deserves comment. Assessment of vascular impedance with a variety of calculations relating to Doppler spectra has received a great deal of attention in the assessment of normal physiology as well as abnormality in certain organs, such as the transplanted kidney. However, little has been published regarding assessment of normal and pathologic splenic arterial impedance. In one study, Nakamura et al. [9] investigated the pulsatility index in splenic, hepatic, and superior mesenteric arteries in fasting subjects and found a significantly lower pulsatility index (and thus lower vascular impedance) in the splenic artery as compared with the superior mesenteric artery. Whether the range of measurements of vascular impedance in the normal splenic artery will permit differentiation from certain pathologic states is an area we believe deserves further investigation; our own limited investigation since the appearance disclosed no instances in which a normal
of this case splenic artery
has has
shown a resistive index of over 80%. At first appraisal, the surgical finding of several rotations of the spleen about its axis and the finding of any flow in the main splenic artery and vein seem discrepant. We offer what we believe is a tenable explanation: Branches of the main splenic artery (short gastric and pancreatic arteries) may remain patent proximal to the site of torsion of the long splenic vascular pedicle characteristic of this disorder. This would allow some antegrade flow through the proximal splenic artery despite increased impedance caused by acute occlusion of the major portion of the splenic arterial bed. Similarly, the presence of a normal direction of blood flow in the main splenic vein most likely relates to continued patency of splenic vein tributaries that join the main spelnic vein beyond the point
of torsion;
such
tributaries
could
include
the
inferior
meSentenc vein or varices that have formed as a result of chronic venous congestion. We anticipate that the pattems of flow in these major vessels could change depending on the exact site of torsion. We believe that the diagnosis of torsion in this case could have been made confidently if CT, sonography, or scintigraphy had been the first test. However, the preliminary diagnosis
the spleen
on scintigraphy
is nonspecific
and
On the other hand, CT is relatively
expensive
sonography,
to
imaging
exposes
the
test in patients
with
patient
nonlocalizing.
compared
with
radiation,
and
ionizing
abdominal
pain; we believe
that
as long as visualization of a torqued spleen is not impaired, the combination of sonography with duplex Doppler and color flow evaluation should allow confident diagnosis of this condition. Confirmatory findings would include absence of the spleen in its normal location and demonstration of a mass elsewhere in the abdomen or pelvis; lack of demonstrable flow within the splenic parenchyma, both on the color flow survey and directed search with duplex Doppler; and possible alterations in main splenic arterial flow, specifically, elevation of the resistive index or other measures of vascular impedance. In summary, we have reported a case of torsion of a wandering spleen for which there is correlative imaging by CT, sonography, and radionuclide scanning. To our knowledge, this is also the first reported case in which duplex Doppler and color flow sonography were used in the diagnostic evaluation
because
splenic parenchymal
of their ability
to noninvasively
evaluate
flow and flow in major splenic vessels.
REFERENCES 1 . Dodds WJ, Taylor imaging of splenic
AJ, Erickson SJ, Stewart ET, Lawson TL. Radiologic anomalies. AJR 1990;155:805-810 2. Woodward OAK. Torsion of the spleen. Am J Surg 1967;1 14:953-955 3. Abell I. Wandering spleen with torsion of the pedicle. Ann Surg 1933:98:722-725
4. Dachman AH. Anomalies
and congenital disorders. In: Friedman AC, ed. Radiology of the liver, bi!iary tract, pancreas and spleen. Baltimore: Wilhams & Wilkins, 1987:917-930 5. Parker LA, Mittelstaedt CA, Mauro MA, Mandell VS, Jacques PF. Torsion of a wandering spleen: CT appearance. J Comput Assist Tomogr 1984;8: 1201 -1204 6. Herman TE, Siegel MJ. CT of acute splenic wandering spleen. AJR 1991;1 56:151-153
torsion
in children
with
7. Kinori I, Rifkin MD. A truly wandering spleen. J Ultrasound Med 1988;7: 101 -1 05 8. Sheflin JR, Lee CM, Kretchmar KA. Torsion of wandering spleen and distal pancreas. AiR 1984:142:100-101 9. Nakamura T, Moriyasu F, Ban N, et al. Quantitative measurement of abdominal arterial flow using image-directed Doppler ultrasonography: superior mesenteric, splenic, and common hepatic arterial blood flow in normal adults. JCU 1989;17:261-268
