Wandering spleen associated with gastric volvulus

Christina Pinto M.D.

Mary Wyers, MD

Children's Memorial Hospital

Abstract

3-year-old male with twenty-four hours of intractable vomiting and right lower quadrant palpable mass.

Keywords

wandering spleen gastric volvulus 1428 ct ugi upper gi


Publication Date: 2008-06-10

History

3-year-old with one day history of vomiting and palpable right lower quadrant abdominal mass.

Findings

IMAGE 1 : Upright KUB: there is a single large fluid level in the mid abdomen as well as a second large fluid level superior to it in the left upper quadrant in the expected location of the stomach.

IMAGE 2 : Ultrasound of the abdomen: a solid organ is identified in the right lower quadrant. No spleen was seen in the left upper quadrant.

IMAGES 3- 8 : CT Abdomen and Pelvis: selected axial, coronal and sagittal images demonstrate an abnormal configuration of the stomach which is severely dilated and filled with fluid. Coronal and sagittal images best depict that the stomach antrum has a beaked or tapered appearance and is superiorly located. The spleen is normally perfused but seen in the right lower quadrant and midline

The majority of the small bowel is positioned in the right lower quadrant lateral to the cecum suggesting malrotation or nonfixation of the bowel.

IMAGES 9-12 : UGI selected images depict a markedly distended stomach with the gastroduodenal junction in an abnormal position in the left upper quadrant superior to the GE junction. Slow gastric emptying was present. The duodenum and proximal small bowel are in an abnormal position in the right abdomen consistent with malrotation or nonfixation.

Diagnosis

Wandering spleen, nonfixation of the bowel, and mesenteroaxial gastric volvulus (confirmed surgically).

Discussion

Gastric volvulus, rarely seen in children, is an abnormal degree of rotation of one part of the stomach around another and can result in gastric inlet or outlet obstruction. Two types of gastric volvulus occur: organoaxial and mesenteroaxial. Organoaxial volvulus is more common, and is rotation around the longitudinal axis of the stomach, such that the greater curvature of the stomach is superior to the lesser curvature. Mesenteroaxial volvulus is rotation of the stomach around the mesenteric axis (at a right angle to the lesser/greater curvature). In an acute setting, volvulus may progress to ischemia and necrosis of the stomach as well as perforation.

Wandering spleen is also a rare condition characterized by the absence or underdevelopment of one or all of the ligaments that hold the spleen in its normal position in the left upper quadrant of the abdomen. A wandering spleen is a mobile spleen that is only attached by an elongated vascular pedicle. This allows it to migrate anywhere within the abdomen or pelvis. Recognizing the presence of a wandering spleen is important because it is prone to splenic torsion.

Wandering spleen and gastric volvulus share a common cause which is the absence of an intraperitoneal visceral ligament resulting in nonfixation. A wandering spleen has a very rare association with gastric volvulus.

Although rare, it is important to remember both of these entities and their association, as both splenic torsion and gastric volvulus are potentially life-threatening if not immediately managed surgically.

References

  1. 1. Wandering spleen : An usual association with gastric volvulus. Liu HM, Lau KK. AJR 2007; 188: W328-W330
  2. 2. Gastric volvulus and wandering spleen. Uc A, Kao SC, Sanders KD, Lawrence J. The American Journal of Gastroenterology, Volume 93, Number 7, 1 July 1998,pp. 1146-1148
  3. 3.Gastric volvulus associated with wandering spleen in a child. Spector JM, Chappell J. J Pediatr Surg 2000;35 : 641-642

16 images