Acute torsion of a wandering spleen: imaging findings B. Bakir, A. Poyanli, E. Yekeler, G. Acunas Department of Radiology, Istanbul Faculty of Medicine, Istanbul University, 34390, Capa, Istanbul, Turkey Abstract Wandering spleen is a rare entity characterized by incom- plete fixation of the spleen by lienorenal and gastrosplenic ligaments. It can migrate to the lower abdomen or pelvis and can be congenital or acquired. We report a case of torsion of a wandering spleen for which there was correlative imaging by ultrasonography, Doppler ultrasonography, computed to- mography, magnetic resonance imaging, and angiography. To our knowledge, this is the first reported case in which all these modalities were used in the diagnostic evaluation. Key words: Wandering spleen—Torsion—Acute abdominal pain Wandering spleen is a rare pathology thought to be the result of underdevelopment or deficiency of ligaments that hold the spleen in its normal position. Although splenomegaly, trauma, and pregnancy play an important role in etiology, it is seen more commonly in women 20 to 40 years old [1, 2]. In children, it is usually due to abnormal development of the dorsal mesogastrium. In this age group, although it is seen between the ages of 3 months and 10 years, the incidence increases in children younger than 1 year [3]. Wandering spleen involves a risk of torsion [4]. Diagnosis is difficult because of lack of symptoms until splenic torsion occurs. Patients may present with an asymptomatic abdominal mass, an acute abdomen, or pain associated with a mass [2]. The most common clinical presentation is an acute, chronic, or intermittent abdominal pain due to splenic torsion [5, 6]. The associated complications are infarction due to arterial occlu- sion, gangrene, functional asplenism, and venous thrombo- sis. In addition, intestinal obstruction, gastric and colonic volvulus, and pancreatitis may occur. Laboratory findings are nonspecific. Diagnosis can be confirmed with imaging techniques [2]. Plain abdominal radiography may show an abdominal mass, in addition to the absence of the spleen in its normal location in the left upper quadrant. Barium enema may show signs of extrinsic compression of the intestinal loops [3]. Absence of splenic parenchyma in the left upper quadrant and ectopic location of the spleen may be observed on ultrasonography (US), computed tomography (CT), and magnetic resonance imaging (MRI). In cases with torsion, Doppler US may show no blood flow in the splenic paren- chyma and hilus. Angiography is a valuable diagnostic method in splenic torsion. Scintigraphy is important for evaluating splenic functions. It may show the absence of radionuclide uptake due to torsion or the abnormally located spleen with a normal uptake. Treatment is splenectomy or splenopexy [7]. Case report A 39-year-old woman was admitted to the hospital with abdominal pain of 1 month’s duration. On physical exami- nation, a mass was palpated in the left lower quadrant. US and CT scans showed the spleen superior to the urinary bladder in the mid left of the abdomen instead of its normal location; hence, “wandering spleen” was diagnosed (Fig. 1A). When the patient returned with abdominal pain 8 months later, US examination showed that the spleen was enlarged and the parenchyma had a granular and hypoechoic appearance. Doppler US demonstrated no blood flow in the splenic hilum and parenchyma. Contrast-enhanced CT scans performed because of a suspicion of splenic torsion showed the spleen to be diffusely hypodense with an enhancing thin pseudocapsule, and the findings were in accordance with torsion (Fig. 1B). MRI depicted the spleen as hypointense in T1-weighted image and hyperintense in T2-weighted image; in contrast, the pseudocapsule appeared hyperintense in T1- weighted image and hypointense in T2-weighted image, which was in accordance with infarction (Fig. 1C). On angiography, the splenic artery was observed clearly until the level of pan- creatic tail. Distal to this level, no artery continuity was ob- served and the spleen could not be visualized. Initiating from the posterior of the pancreas, the splenic vein, portal confluence, and portal venous system were evaluated as clear. With a diagnosis of wandering spleen torsion based on the imaging findings, splenectomy was performed, and the find- ings confirmed the imaging findings. Correspondence to: B. Bakir; email: barisbakir@hotmail.com Abdominal Imaging © Springer Science+Business Media, Inc., 2004 Received: 28 November 2003 / Accepted: 7 January 2004 / Published online: 3 June 2004 Abdom Imaging (2004) 29:707–709 DOI: 10.1007/s00261-004-0174-7