A Solid Mass in Pelvic Region
Article Outline
- Answer to the Clinical Challenges and Images in GI Question: Image 5: Wandering Spleen
- References
- Copyright
Question: A 19-year-old woman was brought into the emergency department by ambulance after a relatively minor motor vehicle accident. On arrival, she was alert and vital signs were stable. She complained of left leg pain, and the examination demonstrated tibia and fibula fractures. Findings of the remaining examination did not demonstrate other injuries. Focused assessment with sonography for trauma (FAST) after placement of an indwelling urethral catheter showed a solid mass in pelvic region (Figure A). She was not pregnant and did not complain of abdominal discomfort. She had no previous history of abdominal surgery. Laboratory studies were within normal limits. Contrast-enhanced computed tomography (CT) scan of the abdomen and pelvis was performed (Figures B–D).
What is the diagnosis?
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Answer to the Clinical Challenges and Images in GI Question: Image 5: Wandering Spleen
Wandering spleen is a rare clinical entity, in which the spleen is free to move from its anatomic position to the lower abdomen or pelvis. It can present as an abdominal or pelvic mass with pain, or as acute surgical abdomen owing to torsion, hemorrhage, or cyst formation. However, the true incidence is unknown because many cases are asymptomatic. This abnormality is incidentally found most commonly in women between the ages of 20 and 40 years.1 Congenital wandering spleen occurs as a result of a deficiency or underdevelopment of the suspensory ligaments of the spleen. Acquired wandering spleen is caused by underlying conditions that may weaken these ligaments, such as the hormonal effects of pregnancy and abdominal wall laxity.2
Doppler ultrasonography3 and CT imaging1 are useful for diagnosis. The diagnosis of a wandering spleen is suggested by the absence of the spleen in the left subphrenic space and the presence of an ectopic spleen-like mass, usually in the pelvis, with a long vascular pedicle. In this case, CT (Figure B) showed the absence of the spleen in the left subphrenic space and a spleen-like mass in the pelvic region (Figure D), suggestive of a wandering spleen. The brightly enhanced lesion was located beside the common iliac artery and inferior vena cava in the lower abdomen (Figure C). Slight ascites (Figure D) may arise as a result of vascular congestion. Three-dimensional reconstruction image of the CT (Figure E) showed that the spleen was suspended by elongated, tortuous splenic vessels flowing into portal vein.
A diagnosis of wandering spleen should be considered when the spleen is absent from its usual position and a homogeneous mass is seen in the abdomen or pelvis. Once wandering spleen is suspected, 3-dimensional CT should be considered, because it shows the features, spleen pedicle, and relative position of visceral organs in a straightforward manner.
References
- Acute abdomen due to torsion of wandering spleen: CT diagnosis. Eur Radiol. 1998;8:1409–1412
- Laparoscopic splenopexy for wandering (pelvic) spleen. Surg Laparosc Endosc. 1998;8:286–290
- Ultrasound diagnosis and Doppler monitoring of a pelvic spleen in pregnancy. Ultrasound Obstet Gynecol. 2001;17:453–454
Conflicts of Interest The authors disclose no conflicts.
For submission instructions, please see the Gastroenterology web site (www.gastrojournal.org).
PII: S0016-5085(09)00189-9
doi:10.1053/j.gastro.2009.02.010
© 2009 AGA Institute. Published by Elsevier Inc. All rights reserved.
