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151
Case
-
CT of Acute Spleen Thomas
E. Herman1
Wandering spleen by laxity on absence
Splenic and Marilyn
is an uncommon of the supporting
Patients with torsion of the wandering
Torsion
in Children
Wandering
J. Siegel
condition splenic
characterized ligaments [1].
spleen may have acute,
chronic, or intermittent symptoms. Although several reports of the sonographic and scintigraphic features of torsion both in children and adults have been published [2-9], little information is available on the CT appearance of torsion, particu-
barly acute torsion [1 0, 1 1 ]. We report two cases of acute splenic torsion in children to show the characteristic CT findings
.
..,
with
Report
Case 2 The second patient was a 2Y2-year-old girl who had had low grade fever and abdominal pain for 1 week. Exploration laparotomy was
performed
for suspected
appendicitis
and showed a normal appendix
but an enlarged spleen. A postoperative CT scan was obtained for evaluation (Fig. 2). On reexploration, the splenic pedicle was torsed
270#{176} and splenic ligaments a hemorrhagic
necrotic
were absent. Pathologic
spleen
with a thick
analysis showed
pseudocapsule.
of this condition. Discussion
Case
Wandering
Reports
splenectomies
Case 1
for a wandering
The first patient was a 2Y2-year-old girl who had a body temperature of 37#{176}C, vomiting, and severe crampy abdominal pain of several hours duration. Physical examination revealed a tender mass in the left upper quadrant. Laboratory studies showed only leukocytosis. Plain radiographs showed an ibeus. Because an abscess was suspected, CT was performed. CT showed absence of the spleen in the left upper quadrant and an avascubar, homogeneous, nonenhancing mass below the lower pole of each kidney, leading to the diagnosis of splenic torsion (Fig. 1). The pancreatic tail was in normal position. During surgery, a 360#{176} torsion of the splenic pedicle resulting in complete splenic infarction was found. The spleen was not attached to the stomach, retroperitoneum, or colon. The tail of the pancreas was not involved, and the remainder of the abdomen appeared normal. Pathologic examination confirmed splenic infarction.
spleen
is a rare condition.
in children, spleen
were
January
1991 0361-803X/91/1561-0151
C American
noted
of 1413
of spbenectomy
by Enkabis and Fibber [12].
Furthermore, in a review of surgical pathology records at Boston Children’s Hospital, Broker et al. [4] reported only three cases in 24 years. A more recent review of the English literature by Allen and Andrews [2] found 35 cases of wandening spleen in children less than 1 0 years old. Eighteen of
these patients presented as acute surgical emergencies, and of these, only eight had the diagnosis of splenic torsion established preoperativeby. Children with wandering spleens months and 1 0 years old; the most
are typically between 3 frequent age at presen-
tation is less than 1 year [2]. Affected patients may be asymptomatic and present with an incidental mass on physical examination, may have mild abdominal pain due to vascular
Received April 26, 1990; accepted after revision June 20, 1990. 1 Both authors: Mallinckrodt Institute of Radiology, Washington University School of Medicine, 51 0 S. Kingshighway requests to T. E. Herman. AJR 156:151-153,
In a review
only four instances
Roentgen Ray Society
Blvd., St. Louis, MO 631 10. Address reprint
HERMAN
Downloaded from www.ajronline.org by Purdue University Library TSS on 03/02/15 from IP address 128.210.126.199. Copyright ARRS. For personal use only; all rights reserved
152
AND
SIEGEL
AJA:156,
Fig. 1.-A, CT scan at level of upper poles of kidney shows absence of splenic tissue. An airfilled dilated transverse colon (C) is present anterior to liver, reflecting a marked ileus. B, CT scan below level of kidneys shows a nonenhancing spleniform mass (M) in left lower quadrant, anterior to partially air-filled colon (arrows).
January 1991
Fig. 2.-CT scan shows low-density, slightly heterogeneous spleniform mass with thick capsule (arrowheads) in left lower quadrant, displacing bowel loops to right. No splenic tissue was present on more cephalad sections. Heterogeneity
within spleen reflects infarcted
areas of hemorrhage
within
spleen.
Fig. 3.-Line drawings of normal development of mesogastrium. (Adapted from Sadler [14].) A, Fifth week of fetal life. Primordial spleen and tail of pancreas form within leaves of dorsal mesogastrium (arrows), which extends from stomach to aorta (Ao). Parietal peritoneum (arrowheads) covers retroperitoneum. B, Sixth week of fetal life. Dorsal portion of pancreas becomes retroperitoneal, with fusion of parietal peritoneum and posterior leaf of dorsal mesogastrium. Unfused portion of dorsal mesogastrium persists as lienorenal ligament (1) and gastrolienal ligament (2) form attachments of spleen.
B
A
congestion or intermittent torsion and spontaneous detonsion, or may present with an acute abdomen due to torsion of the spbenic pedicle with subsequent infarction. With acute torsion,
the condition
can be confused
with appendicitis
or ovarian
torsion. Other clinical findings include nausea, vomiting, fever, leukocytosis, peritoneal signs, and a palpable mass in the abdomen or pelvis. Complications of acute splenic torsion
include gangrene, abscess formation, local peritonitis, tinal obstruction, and necrosis of the pancreatic tail. In adults, particularly women of childbearing torsion has usually been attributed to acquired
such as ligamentous monal
believed
effects
laxity, splenomegaly,
of pregnancy.
to be congenital
Spbenic
bienorenab ligament and the gastrobienal ligament allow some mobility of the spleen normally, but prevent its displacement from a position posterior left kidney. Incomplete
to the stomach and anterior fusion or formation of the
to the dorsal
mesogastrium results in an abnormally mobile spleen with a bong vascular pedicle that is predisposed to torsion. The dorsal pancreatic bud also develops within the dorsal meso-
age, splenic abnormalities
trauma,
and hor-
gastnium.
When
the parietab
peritoneum
and posterior
leaf of
is
the dorsal mesogastnium fuse, the pancreas becomes a netroperitoneab organ [1 4] (Fig. 3B). If the dorsal mesogastrium
Normally the dorsal and its supporting ligaments [1 4] (Fig. bienorenal ligament,
is incomplete or fails to fuse with the panietab penitoneum, portions of the pancreatic tail may be intrapenitoneal and can
torsion
and due to abnormal
of the dorsal mesogastnium [2, 4, 9, 1 3]. mesogastrium gives rise to the spleen structures, the lienorenal and gastrolienal 3). The most important attachment is the
intes-
which arises after fusion of the posterior leaf of the dorsal mesogastnium with the panietal penitoneum in front of the left kidney (Fig. 3B). This ligament attaches the spleen to the posterior body wall and contains the splenic artery. The
in children
development
be involved in splenic torsion. This did not occur in our patients. The normal bienorenal and gastnolienab ligaments can
CT
AJR:156, January 1991
occasionally
Downloaded from www.ajronline.org by Purdue University Library TSS on 03/02/15 from IP address 128.210.126.199. Copyright ARRS. For personal use only; all rights reserved
abdominal
be seen
fat.
on CT in patients
However,
in children
with
who
OF
ACUTE
abundant
have
intra-
a relative
paucity of fat, splenic ligaments are not visualized on CT. Multiple imaging techniques have been used to diagnose wandering spleen, including plain nadiognaphs, barium studies, scintigraphy, sonognaphy, angiognaphy, and more necentby CT [2-1 2]. Plain nadiographs of the abdomen usually have nonspecific findings, but they can suggest the diagnosis by showing an abdominal mass in conjunction with absence of a spbenic shadow in the left upper quadrant. Barium enema findings may be normal on can show displacement by an extrinsic mass. Scintignaphy can be valuable in the evaluation of splenic function and may show either absence of radionuclide uptake due to splenic torsion or normal uptake of nadionucbide by an abnormally positioned spleen. However, scintigraphy has poor anatomic resolution and hence little advantage over studies such as sonography on CT. Sonography and CT are abbe to show the typical comma shape of the spleen in an ectopic position and back of splenic tissue in the left upper quadrant. However, sonognaphy can be hampered by a barge amount of bowel gas. Because CT is not degraded by bowel gas and has an added advantage of being able to establish the presence on absence of perfusion rapidly [1 0-12, 1 5], it is the preferred study for diagnosing wandering spleen and torsion suspected clinically on on other imaging studies. Angiognaphy also can provide definite evidence of splenic torsion and ectopic splenic location, but it is invasive and no longer indicated for diagnosis. The CT manifestations of wandering spleen with acute torsion include (1) absence of the spleen anterior to the left kidney and posterior to the stomach, (2) a lower abdominal or pelvic mass with homogeneous on heterogeneous panenchyma and an attenuation value less than that of normal splenic tissue, and (3) secondary findings such as ascites and necrosis of the pancreatic tail. In reported cases and in the two cases described here, the decreased attenuation was associated with infarction. A thick, enhancing pseudocapsule, representing omental and penitoneab adhesions, has been observed with chronic or intermittent torsion [1 5]. In the second of our two cases, it was associated with acute torsion. When the pancreatic tail is involved, a whorl of pancreatic tissue and fat at the medial bonder of the displaced spleen
SPLENIC
TORSION
153
may be seen on CT [1 1 ]. This was our two cases. The CT appearance
not observed of a torsed
in either of spleen may
be similar to that seen with other cystic lesions, such as an abscess on mesentenic on omentab cysts, but the absence of a spleen in its normal position in the left upper quadrant should
suggest
the diagnosis.
Although rare, splenic torsion should be recognized as a cause of an acute abdomen. Splenectomy is the treatment for
acute
splenic
be performed symptoms infarction
torsion
with
in patients
in whom [2].
the
infarction.
who have chronic diagnosis
is made
Splenopexy
can
on intermittent before
splenic
REFERENCES 1 . Abell
J. Wandering
spleen
with
torsion
of the pedicle.
Ann
Surg
1933;98:722-735
2. Allen KB, Andrews G. Pediatric wandering spleen-the case for splenopexy: review of 35 reported cases in the literature. J Pediatr Surg 1989;24:432-435
3. Barki Y, Bar-Ziv J. Wandering spleen in two children: the role of ultrasonic diagnosis. Br J Radiol 1984;57:267-270 4. Broker FHL, Fellows K, Treves S. Wandering spleen in three children. Pediatr Radiol 1978;6:21
1-214
5. Gordon DH, Burrell Ml, Levin DC, Mueller CF, Becker JA. Wandering spleen: the radiological and clinical spectrum. Radiology 1977;125:39-46 6. Hunter TB, Haber K. Sonographic diagnosis of a wandering spleen. Radiology
1977;129:925-926
7. Rosenthall L, Lisbona A, Banerjee K. A nucleographic and radioangiographic study of a patient with torsion of the spleen. Radiology 1974; 110:427-428 8. Setiawan H, Harrell AS, Perret AS. Ectopic spleen: a sonographic diagnosis. Pediatr Radiol 1982;12: 152-153 9. Thompson JS, Ross AJ, Pizzaro ST. The wandering spleen in infancy and childhood. Clin Pediatr 1980;19:221-224 10. Parker LA, Mittelstaedt CA, Mauro MA, Mandell vs, Jaques PF. Torsion of a wandering
spleen:
CT appearance.
J Comput
Assist
Tomogr
1984;
8:1201-1203 1 1 . Sheflin JA, Lee CM, Kretchmar KA. Torsion of wandering spleen and distal pancreas. AJR 1984;142:100-104 12. Erkalis AJ, Filler AM. Splenectomy in childhood: a review of 1413 cases. J Pediatr
13. Woodward
Surg
1972;7:382-388
DAK. Torsion of the spleen. Am J Surg 1967;1 14:953-955 14. Sadler TW. Langman’s medical embryology, 5th ed. Baltimore: Williams & Wilkins, 1967:953-955 15. Shiels WE, Johnson JF, Stephenson SA, Huang YC. Chronic torsion of the wandering spleen. Pediatr Radio! 1989;19:465-467
151
Case
-
CT of Acute Spleen Thomas
E. Herman1
Wandering spleen by laxity on absence
Splenic and Marilyn
is an uncommon of the supporting
Patients with torsion of the wandering
Torsion
in Children
Wandering
J. Siegel
condition splenic
characterized ligaments [1].
spleen may have acute,
chronic, or intermittent symptoms. Although several reports of the sonographic and scintigraphic features of torsion both in children and adults have been published [2-9], little information is available on the CT appearance of torsion, particu-
barly acute torsion [1 0, 1 1 ]. We report two cases of acute splenic torsion in children to show the characteristic CT findings
.
..,
with
Report
Case 2 The second patient was a 2Y2-year-old girl who had had low grade fever and abdominal pain for 1 week. Exploration laparotomy was
performed
for suspected
appendicitis
and showed a normal appendix
but an enlarged spleen. A postoperative CT scan was obtained for evaluation (Fig. 2). On reexploration, the splenic pedicle was torsed
270#{176} and splenic ligaments a hemorrhagic
necrotic
were absent. Pathologic
spleen
with a thick
analysis showed
pseudocapsule.
of this condition. Discussion
Case
Wandering
Reports
splenectomies
Case 1
for a wandering
The first patient was a 2Y2-year-old girl who had a body temperature of 37#{176}C, vomiting, and severe crampy abdominal pain of several hours duration. Physical examination revealed a tender mass in the left upper quadrant. Laboratory studies showed only leukocytosis. Plain radiographs showed an ibeus. Because an abscess was suspected, CT was performed. CT showed absence of the spleen in the left upper quadrant and an avascubar, homogeneous, nonenhancing mass below the lower pole of each kidney, leading to the diagnosis of splenic torsion (Fig. 1). The pancreatic tail was in normal position. During surgery, a 360#{176} torsion of the splenic pedicle resulting in complete splenic infarction was found. The spleen was not attached to the stomach, retroperitoneum, or colon. The tail of the pancreas was not involved, and the remainder of the abdomen appeared normal. Pathologic examination confirmed splenic infarction.
spleen
is a rare condition.
in children, spleen
were
January
1991 0361-803X/91/1561-0151
C American
noted
of 1413
of spbenectomy
by Enkabis and Fibber [12].
Furthermore, in a review of surgical pathology records at Boston Children’s Hospital, Broker et al. [4] reported only three cases in 24 years. A more recent review of the English literature by Allen and Andrews [2] found 35 cases of wandening spleen in children less than 1 0 years old. Eighteen of
these patients presented as acute surgical emergencies, and of these, only eight had the diagnosis of splenic torsion established preoperativeby. Children with wandering spleens months and 1 0 years old; the most
are typically between 3 frequent age at presen-
tation is less than 1 year [2]. Affected patients may be asymptomatic and present with an incidental mass on physical examination, may have mild abdominal pain due to vascular
Received April 26, 1990; accepted after revision June 20, 1990. 1 Both authors: Mallinckrodt Institute of Radiology, Washington University School of Medicine, 51 0 S. Kingshighway requests to T. E. Herman. AJR 156:151-153,
In a review
only four instances
Roentgen Ray Society
Blvd., St. Louis, MO 631 10. Address reprint
HERMAN
Downloaded from www.ajronline.org by Purdue University Library TSS on 03/02/15 from IP address 128.210.126.199. Copyright ARRS. For personal use only; all rights reserved
152
AND
SIEGEL
AJA:156,
Fig. 1.-A, CT scan at level of upper poles of kidney shows absence of splenic tissue. An airfilled dilated transverse colon (C) is present anterior to liver, reflecting a marked ileus. B, CT scan below level of kidneys shows a nonenhancing spleniform mass (M) in left lower quadrant, anterior to partially air-filled colon (arrows).
January 1991
Fig. 2.-CT scan shows low-density, slightly heterogeneous spleniform mass with thick capsule (arrowheads) in left lower quadrant, displacing bowel loops to right. No splenic tissue was present on more cephalad sections. Heterogeneity
within spleen reflects infarcted
areas of hemorrhage
within
spleen.
Fig. 3.-Line drawings of normal development of mesogastrium. (Adapted from Sadler [14].) A, Fifth week of fetal life. Primordial spleen and tail of pancreas form within leaves of dorsal mesogastrium (arrows), which extends from stomach to aorta (Ao). Parietal peritoneum (arrowheads) covers retroperitoneum. B, Sixth week of fetal life. Dorsal portion of pancreas becomes retroperitoneal, with fusion of parietal peritoneum and posterior leaf of dorsal mesogastrium. Unfused portion of dorsal mesogastrium persists as lienorenal ligament (1) and gastrolienal ligament (2) form attachments of spleen.
B
A
congestion or intermittent torsion and spontaneous detonsion, or may present with an acute abdomen due to torsion of the spbenic pedicle with subsequent infarction. With acute torsion,
the condition
can be confused
with appendicitis
or ovarian
torsion. Other clinical findings include nausea, vomiting, fever, leukocytosis, peritoneal signs, and a palpable mass in the abdomen or pelvis. Complications of acute splenic torsion
include gangrene, abscess formation, local peritonitis, tinal obstruction, and necrosis of the pancreatic tail. In adults, particularly women of childbearing torsion has usually been attributed to acquired
such as ligamentous monal
believed
effects
laxity, splenomegaly,
of pregnancy.
to be congenital
Spbenic
bienorenab ligament and the gastrobienal ligament allow some mobility of the spleen normally, but prevent its displacement from a position posterior left kidney. Incomplete
to the stomach and anterior fusion or formation of the
to the dorsal
mesogastrium results in an abnormally mobile spleen with a bong vascular pedicle that is predisposed to torsion. The dorsal pancreatic bud also develops within the dorsal meso-
age, splenic abnormalities
trauma,
and hor-
gastnium.
When
the parietab
peritoneum
and posterior
leaf of
is
the dorsal mesogastnium fuse, the pancreas becomes a netroperitoneab organ [1 4] (Fig. 3B). If the dorsal mesogastrium
Normally the dorsal and its supporting ligaments [1 4] (Fig. bienorenal ligament,
is incomplete or fails to fuse with the panietab penitoneum, portions of the pancreatic tail may be intrapenitoneal and can
torsion
and due to abnormal
of the dorsal mesogastnium [2, 4, 9, 1 3]. mesogastrium gives rise to the spleen structures, the lienorenal and gastrolienal 3). The most important attachment is the
intes-
which arises after fusion of the posterior leaf of the dorsal mesogastnium with the panietal penitoneum in front of the left kidney (Fig. 3B). This ligament attaches the spleen to the posterior body wall and contains the splenic artery. The
in children
development
be involved in splenic torsion. This did not occur in our patients. The normal bienorenal and gastnolienab ligaments can
CT
AJR:156, January 1991
occasionally
Downloaded from www.ajronline.org by Purdue University Library TSS on 03/02/15 from IP address 128.210.126.199. Copyright ARRS. For personal use only; all rights reserved
abdominal
be seen
fat.
on CT in patients
However,
in children
with
who
OF
ACUTE
abundant
have
intra-
a relative
paucity of fat, splenic ligaments are not visualized on CT. Multiple imaging techniques have been used to diagnose wandering spleen, including plain nadiognaphs, barium studies, scintigraphy, sonognaphy, angiognaphy, and more necentby CT [2-1 2]. Plain nadiographs of the abdomen usually have nonspecific findings, but they can suggest the diagnosis by showing an abdominal mass in conjunction with absence of a spbenic shadow in the left upper quadrant. Barium enema findings may be normal on can show displacement by an extrinsic mass. Scintignaphy can be valuable in the evaluation of splenic function and may show either absence of radionuclide uptake due to splenic torsion or normal uptake of nadionucbide by an abnormally positioned spleen. However, scintigraphy has poor anatomic resolution and hence little advantage over studies such as sonography on CT. Sonography and CT are abbe to show the typical comma shape of the spleen in an ectopic position and back of splenic tissue in the left upper quadrant. However, sonognaphy can be hampered by a barge amount of bowel gas. Because CT is not degraded by bowel gas and has an added advantage of being able to establish the presence on absence of perfusion rapidly [1 0-12, 1 5], it is the preferred study for diagnosing wandering spleen and torsion suspected clinically on on other imaging studies. Angiognaphy also can provide definite evidence of splenic torsion and ectopic splenic location, but it is invasive and no longer indicated for diagnosis. The CT manifestations of wandering spleen with acute torsion include (1) absence of the spleen anterior to the left kidney and posterior to the stomach, (2) a lower abdominal or pelvic mass with homogeneous on heterogeneous panenchyma and an attenuation value less than that of normal splenic tissue, and (3) secondary findings such as ascites and necrosis of the pancreatic tail. In reported cases and in the two cases described here, the decreased attenuation was associated with infarction. A thick, enhancing pseudocapsule, representing omental and penitoneab adhesions, has been observed with chronic or intermittent torsion [1 5]. In the second of our two cases, it was associated with acute torsion. When the pancreatic tail is involved, a whorl of pancreatic tissue and fat at the medial bonder of the displaced spleen
SPLENIC
TORSION
153
may be seen on CT [1 1 ]. This was our two cases. The CT appearance
not observed of a torsed
in either of spleen may
be similar to that seen with other cystic lesions, such as an abscess on mesentenic on omentab cysts, but the absence of a spleen in its normal position in the left upper quadrant should
suggest
the diagnosis.
Although rare, splenic torsion should be recognized as a cause of an acute abdomen. Splenectomy is the treatment for
acute
splenic
be performed symptoms infarction
torsion
with
in patients
in whom [2].
the
infarction.
who have chronic diagnosis
is made
Splenopexy
can
on intermittent before
splenic
REFERENCES 1 . Abell
J. Wandering
spleen
with
torsion
of the pedicle.
Ann
Surg
1933;98:722-735
2. Allen KB, Andrews G. Pediatric wandering spleen-the case for splenopexy: review of 35 reported cases in the literature. J Pediatr Surg 1989;24:432-435
3. Barki Y, Bar-Ziv J. Wandering spleen in two children: the role of ultrasonic diagnosis. Br J Radiol 1984;57:267-270 4. Broker FHL, Fellows K, Treves S. Wandering spleen in three children. Pediatr Radiol 1978;6:21
1-214
5. Gordon DH, Burrell Ml, Levin DC, Mueller CF, Becker JA. Wandering spleen: the radiological and clinical spectrum. Radiology 1977;125:39-46 6. Hunter TB, Haber K. Sonographic diagnosis of a wandering spleen. Radiology
1977;129:925-926
7. Rosenthall L, Lisbona A, Banerjee K. A nucleographic and radioangiographic study of a patient with torsion of the spleen. Radiology 1974; 110:427-428 8. Setiawan H, Harrell AS, Perret AS. Ectopic spleen: a sonographic diagnosis. Pediatr Radiol 1982;12: 152-153 9. Thompson JS, Ross AJ, Pizzaro ST. The wandering spleen in infancy and childhood. Clin Pediatr 1980;19:221-224 10. Parker LA, Mittelstaedt CA, Mauro MA, Mandell vs, Jaques PF. Torsion of a wandering
spleen:
CT appearance.
J Comput
Assist
Tomogr
1984;
8:1201-1203 1 1 . Sheflin JA, Lee CM, Kretchmar KA. Torsion of wandering spleen and distal pancreas. AJR 1984;142:100-104 12. Erkalis AJ, Filler AM. Splenectomy in childhood: a review of 1413 cases. J Pediatr
13. Woodward
Surg
1972;7:382-388
DAK. Torsion of the spleen. Am J Surg 1967;1 14:953-955 14. Sadler TW. Langman’s medical embryology, 5th ed. Baltimore: Williams & Wilkins, 1967:953-955 15. Shiels WE, Johnson JF, Stephenson SA, Huang YC. Chronic torsion of the wandering spleen. Pediatr Radio! 1989;19:465-467
