Riva Das, MD1, Daniel A Ringold, MD2, Thai Q Vu, MD2. 1Orlando Health, 2Abington Jefferson Health
Introduction: Spenules, or accessory spleens, are a rare disease entity. Most often, they are asymptomatic, and found incidentally during radiographic workup for an unrelated problem. Torsion can cause a splenule to not only become symptomatic, but also confound the results of usual diagnostic studies.
Case Description: A 61-year-old female patient with history of uncomplicated hypertension, hyperlipidemia, hysterectomy, cholecystectomy, spinal surgery, and partial left nephrectomy, presented to the hospital with a two-week history of intermittent left upper quadrant abdominal pain. She denied any similar episodes in the past, or any associated symptoms. Further investigation with a CT scan of the abdomen and pelvis showed an acute inflammatory process in the left upper quadrant in same location as some colonic diverticulosis, as well as a 4.5 cm soft tissue mass. This indeterminate soft tissue mass was described as having decreased attenuation compared with the spleen. Differential diagnosis for this mass included malignancy, an atypical splenule, or an infectious/inflammatory mass. An MRI was recommended for further evaluation, but did not reveal any additional significant findings. Nuclear medicine liver/spleen scintigraphy was performed, which showed no focal activity associated with the indeterminate left upper quadrant mass, therefore making it unlikely to reflect a splenule, and making malignancy the diagnosis of exclusion. Following a period of observation with analgesia, intravenous antibiotics, and bowel rest, her abdominal pain did not resolve, and the decision was made to proceed with operative exploration. Diagnostic laparoscopy revealed an approximately 5 cm spherical mass in the left upper quadrant located just below the inferior aspect of the spleen. The superior aspect of the mass gave rise to a vascular pedicle, which upon tracing, seemed to originate from the splenic hilum. This pedicle was easily ligated, and the mass removed. Pathology revealed an extensive infarcted hemorrhagic nodule with organizing thrombus and attached thrombosed artery, consistent with an infarcted splenule due to torsion along its own axis. The patient had an uncomplicated post-operative course.
Discussion: This case report demonstrates the unusual presentation and workup of a patient that was ultimately diagnosed with an infarcted splenule, despite imaging findings that did not correlate, and may even have confused her diagnosis. Scintigraphy, which is normally the gold standard for diagnosing and localizing accessory splenic tissue, was in this case unrevealing, due to inability of the tracer to traverse the torsed vascular pedicle. Operative exploration was both diagnostic and therapeutic.
Presented at the SAGES 2017 Annual Meeting in Houston, TX.
Abstract ID: 88377
Program Number: P189
Presentation Session: iPoster Session (Non CME)
Presentation Type: Poster
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