期刊名称：Journal of Education and Teaching in Emergency Medicine
印刷版ISSN：2474-1949
出版年度：2019
卷号：4
期号：3
页码：1-3
DOI：10.21980/J8PS7C
出版社：University of California Press
摘要：History of present illness: A 7-month-old boy presented for evaluation of an abdominal mass. Two weeks
prior, the patient had a fever followed by 24 hours of vomiting and abdominal pain, which self-resolved. His
pediatrician noted the mass on exam and referred child to the emergency department (ED). His abdominal
exam was significant for a hard mass palpated to the left of the umbilicus.
Significant findings: Computed tomography (CT) of the abdomen showed displacement of spleen (red
arrow), lying in the left mid abdomen anterior to the left kidney (green arrow), and inferior to the stomach
(grey arrow). The spleen is normally located in the left upper quadrant of abdomen just inferior to the
diaphragm. The liver (blue arrow) is in the proper anatomic position in the right upper quadrant and of
normal density. The spleen is diffusely hypodense, with a visible capsule representing an enlarged, wandering
spleen with complete infarction without evidence of free fluid or rupture.
A normalspleen should have a density appearance similarto that of the liver, due to the intravenous contrast
and should appear white on CT imaging in the vasculature and body of the organ. The splenic capsule often
has a separate blood supply compared to the splenic body, thus is also white on the imaging, and despite the
infarction of the spleen, is seen highlighting the outline of the organ.
Discussion: A wandering spleen is a rare condition with a reported incidence of < 0.2% of birth defects.1 Most
commonly, it is diagnosed in patients under one year of age with a male predominance of 6:1.2 The
pathophysiology is a loss or weakening of the ligaments that hold the spleen fixed causing the spleen to
“wander” from its normal anatomic position. Most cases are thought to be congenital, but there are cases of
acquired wandering spleen secondary to abdominal trauma. One third of all reported cases are in children.
In a majority of cases, a wandering spleen is asymptomatic. Patients can also present with splenomegaly, an
unspecified abdominal mass, recurrent episodes of abdominal pain, intestinal obstruction, nausea, vomiting,
or fever. It is thought that the abdominal pain typically comes in episodes when the splenic vasculature is
twisting and untwisting due to its mobility.3
In the emergency department, prompt and thorough evaluation of the abdomen is critical to rule out an
acute surgical abdomen. Patients with a wandering spleen can present with acute hemorrhage, as well as
ischemia. Monitoring complete blood counts, pain control, and appropriate fluid resuscitation are necessary.
Treatment of a wandering spleen is a splenopexy to surgically fixate the spleen in the left upper quadrant.
However, if there is no blood flow to the spleen even after detorsing, a splenectomy is performed.4 At the
time of our patient’s presentation, the spleen was completely infarcted with evidence of ischemia on CT scan.
The likelihood of return flow to the spleen was deemed unlikely. The decision was made to delay surgery
because the spleen will likely necrose and surgery can be performed electively on an outpatient basis if
required. Some recommendationsforsimilar casesstate thatsplenectomy is necessary in cases of completely
infarcted spleens, especially if the presentation is an acute surgical abdomen. 2,3 The decision to not operate
at the time of presentation is indicative of the most conservative management of a wandering spleen.2,3 If the patient suffers complications with conservative management, such as chronic abdominal pain, abnormal
enlargement of the spleen, and/or abnormalities of the complete blood count, the treatment of choice is to
proceed with splenectomy.3
As a result of the wandering spleen, patients become functionally asplenic, and are at risk for invasive
bacterial infections from encapsulated organisms. Thus, especially for younger patients, prophylactic
antibiotics are indicated; our patient was started on prophylactic penicillin at time of discharge from the ED.
