Wandering spleen caused by subcapsular haemorrhage: BMJ case
A 51-year-old woman 8 years post- human leukocyte antigen (HLA)-matched allogeneic haematopoietic cell transplant presented to her gynaecologist with abdominal pain and a new, large abdominopelvic mass that had gradually grown over a few weeks. She reported severe vomiting followed by days of debilitating abdominal pain during a self-limited gastroenteritis 4 weeks earlier. Her medical history was notable for follicular lymphoma with associated splenomegaly.

While she achieved complete remission after haematopoietic cell transplant, she continued to have thrombocytopaenia. She had no history of abdominal surgery and had one vaginal birth. At presentation, she complained of mild abdominal pain and fullness in her lower abdomen and denied other systemic or gastrointestinal symptoms. Her physical examination was notable only for a firm, non-tender abdominopelvic mass spanning most of her lower abdomen.

Her labs were significant for thrombocytopaenia (132 k/uL) and mildly low white blood cell count (WBC 2.79 K/uL) and a normal haemoglobin and haematocrit (12.3 g/dL/36.9%). A CT scan with intravenous contrast was performed and compared with prior scans. Imaging showed the spleen and an accompanying large subcapsular haematoma forming the large pelvic mass.

The subcapsular haematoma disrupted the spleen’s normal ligamentous attachments and had pulled it from its normal location into the pelvis by gravity. During her uncomplicated open splenectomy, it was revealed that all normal attachments to the spleen were absent except for the vascular pedicle at the splenic hilum.

She recovered well and by postoperative week 4, her blood counts normalised (WBC 5.47 K/uL, haemoglobin 12.7 g/dL, haematocrit 38.5%, platelets 469 k/uL).

Her final pathology revealed a 17×12×5 cm spleen with congestion and without evidence of lymphoma. The only identifiable aetiology for the subcapsular splenic haemorrhage was the episode of severe emesis 2 months prior to presentation in the setting of relative thrombocytopaenia.

Learning points
• Splenic subcapsular haematomas, previous pregnancies, splenomegaly and lymphoma are risk factors for a wandering spleen.

• CT scan is the preferred diagnostic study and a delay in diagnosis can result in torsion of the splenic vascular pedicle and splenic necrosis, leading to an acute abdomen.

• Both splenectomy and splenopexy are surgical options, but splenopexy preserves the immunological function of the spleen.

Read more here: http://casereports.bmj.com/content/2018/bcr-2018-224917.full