Wandering Spleen

The suspending ligaments of the spleen may be absent or may elongate due to congenital or acquired causes, leading to a migration of the spleen from its normal location in the left upper quadrant on an elongated pedicle containing splenic vessels. This is called a "wandering spleen" (Fig. 2-61) and renders that organ susceptible to torsion and possible infarction. It occurs most frequently in women of childbearing age. The clinical diagnosis of this entity can be very difficult.114-116 Patients may have an asymptomatic mass, a mass with sub-

Wandering Spleen

Fig. 2—57. Schematic cross-sectional diagram through the upper abdomen reveals continued rotation of the elongated mesogastrium containing the splenic bud.

This rotation brings the dorsal mesentery to lie along the posterior abdominal wall. Eventual involution and fusion of the mesentery leaves the lienorenal ligament (L.R.L.) as its remnant. The gastrosplenic ligament (G.S.L.) forms one of the borders of the lesser sac. The gastrohepatic ligament (G.H.L.) persists as the lesser omentum. The falciform ligament (F.L.) continues to separate the right side of the peritoneum from the left, anteriorly and superiorly in the subphrenic space. (From Javors BR, Sloves JH.4)

Fig. 2—57. Schematic cross-sectional diagram through the upper abdomen reveals continued rotation of the elongated mesogastrium containing the splenic bud.

This rotation brings the dorsal mesentery to lie along the posterior abdominal wall. Eventual involution and fusion of the mesentery leaves the lienorenal ligament (L.R.L.) as its remnant. The gastrosplenic ligament (G.S.L.) forms one of the borders of the lesser sac. The gastrohepatic ligament (G.H.L.) persists as the lesser omentum. The falciform ligament (F.L.) continues to separate the right side of the peritoneum from the left, anteriorly and superiorly in the subphrenic space. (From Javors BR, Sloves JH.4)

Accessory Spleen

Fig. 2—58. Accessory spleen.

Contrast-enhanced CT scan demonstrates nodule of accessory spleen (As) in the hilus of the spleen (Sp) within the branching of the splenic artery. LK = left kidney; A = adrenal gland; St = stomach.

Omentum Nodule And Falciform

Fig. 2-59. Hypertrophied residual accessory spleen.

Nephrotomogram in a postsplenectomy patient shows lateral deviation of the left kidney and demonstrates the soft-tissue mass of an accessory spleen (AS), presumably hypertrophied. The accessory spleen was further verified by arteriography and a splenic scan. The normal left adrenal gland (A) is also identified.

Fig. 2-59. Hypertrophied residual accessory spleen.

Nephrotomogram in a postsplenectomy patient shows lateral deviation of the left kidney and demonstrates the soft-tissue mass of an accessory spleen (AS), presumably hypertrophied. The accessory spleen was further verified by arteriography and a splenic scan. The normal left adrenal gland (A) is also identified.

acute abdominal or gastrointestinal symptoms, or acute abdominal findings. When there is uncertainty whether the mass truly represents an ectopically located spleen, radionuclide imaging with technetium-99m (99mTc) sulfur colloid can resolve the dilemma. Most commonly, the pedicle becomes constricted because of torsion, and venous occlusion causes splenic congestion and progressive enlargement. Complete occlusion may result in hemorrhagic infarction, subcapsular hemorrhage, gangrene, or functional asplenism. Barium enema studies may demonstrate medial and anterior displacement of the splenic flexure or a bandlike colonic impression caused by the pressure from the splenic pedicle. The classic radiographic findings of torsion include an ec-topic location and on CT, a whirled appearance along its medial aspect117,118 (Fig. 2-62). Torsion of a wandering accessory spleen has also been reported.119

Fig. 2-60. Overlooked accessory spleen, postsplenectomy, in a patient with bleeding disorder.

Heat-damaged red blood cell radionuclide scan shows a small focus of activity in the anterior left upper quadrant consistent with an accessory spleen. The patient had idiopathic thrombocytopenic purpura, and a previous splenectomy had failed to correct the low platelet count. The presence of an accessory spleen was confirmed at laparotomy. (Courtesy of Sam Wang, M.D.)

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