Wandering spleen presenting with torsion, ITP exacerbation

Eric W Owings, MD, Sagar Gandhi, MD, Todd Nickloes, DO, Andrea M Alexander, MD. Univsity of Tennessee Medical Center Knoxville.

Introduction: Wandering spleen is a rare medical condition in which the spleen is not located in the left upper quadrant but rather in variable locations of the dependent abdomen due to the absence of peritoneal attachments. The condition is often asymptomatic but presentation is variable from abdominal pain, nausea, vomiting and obstipation as a result of splenic torsion and ischemia. We present a case of an elderly white female with a known history of idiopathic thrombocytopenic purpura (ITP) presenting with symptoms consistent with a bowel obstruction, who was diagnosed with a wandering spleen and subsequently developed an ITP exacerbation requiring laparoscopic splenectomy.

Case Description: A 78 year old multiparous white female presented with worsening abdominal pain, nausea and vomiting three days prior to admission. She had a past medical history of idiopathic thrombocytopenic purpura, gastroesophageal reflux disease and Wolff-Parkinson-White syndrome status post ablation. Physical exam revealed a palpable mass in the right lower quadrant, CBC unremarkable with a platelet count of 77,000. CT scan initially revealed a non-enhancing mass in the pelvis and absence of a spleen in the left upper quadrant. On hospital day 3, the patient’s physical complaints had resolved but had an acute drop in her platelets to 6,000. She was treated with high dose steroids and IVIG with no resolution of the thrombocytopenia. Repeat CT scan revealed a partially enhancing spleen with partial torsion in the pelvis. The patient’s platelets were repleted and successfully underwent laparoscopic hand assisted splenectomy. Intraoperative findings confirmed a wandering spleen without peritoneal attachments and a long splenic artery and vein. The post operative course was uncomplicated and the platelet level was greater than 100,000 upon discharge. At three weeks post operative, the patient is noted to be doing well with platelets within normal range.

Discussion: This case presents a common clinical scenario but an unusual diagnosis and hospital course. Awareness of this rare condition may enhance diagnostic acumen.

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