twist and shout….
the case.
34 year old female presents to ED with a 2 day history of worsening left-sided pleuritic chest pain associated with shortness of breath. There has been no associated cough, fever or sputum production.
She is one week post-Caesarian section; an uncomplicated, elective procedure from which she has recovered well.
PMHx:
- prior LCSC (5 years ago)
- Splenomegaly (?cause)
- No regular medications
- Penicillin allergy
On examination.
Alert but distressed in pain, able to speak in full sentences.
P 102, BP 126/70, RR 22, SaO2 99% (on air).
Afebrile.
Heart sounds dual without rub or murmur.
Chest: Clear without crackles/wheeze. No pleural rub. Non-tender chest wall without rashes or vesicles.
Abdomen: Soft & NT with palpable spleen. Appropriately healing Caesarian scar.
No unilateral calf swelling or pitting oedema.
[DDET What are your DDx in this case?]
- Pulmonary embolism
- Pneumonia
- Pneumothorax
- Pleural effusion ?cause
- Subphrenic pathology (including post-operative collection)
- ….other ??
[/DDET]
[DDET Her basic results are as follows…]
- Hb 108, WCC 11.2, PLT 460
- EUC/LFTs normal
- ECG: Sinus tachycardia without features of right heart strain or myocardial ischaemia
Her is her CXR…
[/DDET]
[DDET What do you do now?]
Given the high pretest probability for PE and the lack of an obvious alternate diagnosis, you elect to proceed straight to advanced imaging and send your patient for a CTPA.
Here is her scan…
[DDET The CT report…]
- Suboptimal study; however no pulmonary embolism is demonstrated.
- There is mild dependent atelectasis, worse on left.
- The spleen is enlarged and its hilum faces laterally with varices. It also appears to sit inferiorly to its normal position (under the stomach & liver, and does not contact the diaphragm). It does not demonstrate its normal mottled appearance on the arterial phase.
[/DDET]
[/DDET]
[DDET The case continues…]
Following a period of observation and titrated analgesia our patient settled and her observations normalised.
She was soon keen to go home and keep her newborn out of hospital. She was subsequently discharged with return precautions and a plan to followup with her GP the next morning.
[DDET 24 hours later, the phone rings….]
The consultant radiologist has reviewed the images and amended the report.
It now reads;
” The spleen is enlarged and it is also rotated. It does not enhance normally and there is mild surrounding stranding. The splenic artery cannot be followed completely to the hilum. These findings are suspicious for splenic torsion.”
The patient is called back to the department and the diagnosis explained. She is admitted under the care of the surgeons and she undergoes further advanced imaging….
[DDET In more detail….]
[/DDET]
[/DDET]
[/DDET]
[DDET The Diagnosis]
SPLENIC TORSION.
There are multiple case reports of spontaneous splenic torsion, typically relating to “a wandering spleen“.
What is a wandering spleen?
It is a rare condition characterised by the abnormal location of the spleen in the lower abdomen or pelvis. This results from increased splenic mobility due to the absence or laxity of its suspensory ligaments.
Wandering spleen has been described in patients ranging from 3 months to 82 years of age. It has an incidence of <0.25% of all splenectomies.
CAUSES.
The causes of wandering spleen can be both congenital and acquired, with acquired risk factors including pregnancy, trauma & splenomegaly.
It can occur in all age groups, but classically occurs in 20-40 year old females. There are multiple case reports of splenic infarction occurring in postpartum women.
PRESENTATION.
A wandering spleen may present clinically as an acute surgical abdomen secondary to torsion of the spleen around its vascular pedicle. This subsequently leads to splenic capsular stretch, ischaemia and infarction.
Although wandering spleen may be found incidentally as a mass in the abdomen without causing any complaint, it may cause chronic, subacute or acute abdominal pain secondary to torsion of the splenic pedicle resulting in vascular inflow and outflow thrombosis.
They are often found incidentally at surgery for completely unrelated complaints.
COMPLICATIONS.
- Acute torsion of the splenic pedicle with splenic infarction (most common complication)
- Acute pancreatitis (due to pancreatic tail obstruction)
- Upper GIT haemorrhage (from gastric fundus varices)
MANAGEMENT.
Splenectomy vs Splenopexy.
- Splenic infarction typically requires splenectomy
- Spleen preserving strategies (splenopexy) are reserved for healthy & non-infarcted spleens that are of normal size and without signs of hypersplenism.
- They are highly recommended in paediatric patients to minimise the risk of post-splenectomy septicaemia.
[/DDET]
[DDET Case conclusion]
- Over the next 4 days in hospital our patient is managed conservatively with analgesia.
- During this time she developed thrombocytosis (PLT > 1100) and was commenced on aspirin.
- Given the fact she is now functionally asplenic, she was immunised according to a splenectomy program and was also commenced on roxithromycin 150mg daily (for prophylaxis, given penicillin allergy).
- She received strict instructions on urgent medical review with onset of fever.
[/DDET]
[DDET References]
- Magowska, A. (2013). Wandering spleen: a medical enigma, its natural history and rationalization. World Journal of Surgery, 37(3), 545–550. doi:10.1007/s00268-012-1880-x
- Alimoglu, O., Sahin, M., & Akdag, M. (2004). Torsion of a wandering spleen presenting with acute abdomen: a case report. Acta Chirurgica Belgica, 104(2), 221–223.
- Anyfantakis, D., et al. (2013). Acute torsion of a wandering spleen in a post-partum female: A case report. International journal of surgery case reports, 4(8), 675–677. doi:10.1016/j.ijscr.2013.05.002
[/DDET]
