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Traduction de spleen – dictionnaire anglais-français

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Wandering spleen: Diagnosis and treatment

Affiliations.

• 1 Department of Visceral, Metabolic and Cancer Surgery, Nancy University Hospital - Brabois Adult Hospital, rue du Morvan, 54511 Vandœuvre-lès-Nancy, France. Electronic address: [email protected].
• 2 Department of Visceral, Metabolic and Cancer Surgery, Nancy University Hospital - Brabois Adult Hospital, rue du Morvan, 54511 Vandœuvre-lès-Nancy, France.
• PMID: 38839447
• DOI: 10.1016/j.jviscsurg.2024.05.005

Whether congenital or acquired, wandering spleen is a rare entity. In most cases, surgical treatment necessitates splenectomy, or even more rarely, particularly in children, splenopexy.

Keywords: Splenectomy; Splenopexy; Wandering spleen.

Copyright © 2024. Published by Elsevier Masson SAS.

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• American English : spleen / sˈplin /
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• French : rate
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• v.5(3); 2017 Aug

Wandering spleen: a surgical enigma

Ashok kumar puranik.

1 Department of Surgery, Command Hospital, Pune, Maharashtra, India and

Rohit Mehra

2 Department of Surgery, Armed Forces Medical College, Pune, Maharashtra, India

Sushila Chauhan

Rahul pandey.

Wandering spleen, also referred to as ‘ptotic spleen’, is a rare clinical condition characterized by splenic migration form its normal left hypochondrial position to any other abdominal or pelvic position. Among the multifactorial etiologies proposed, laxity of the spleen’s primary supporting ligaments is the most agreed-upon hypothesis. We present one rare case of wandering spleen in an 11-year-old girl who presented with recurrent abdominal pain with no localizing features. Her abdominal examination revealed an intra-abdominal left iliac fossa lump with restricted mobility, which was confirmed as a wandering spleen by abdominal sonography and contrast-enhanced computed tomography. Intraoperatively, an infarcted spleen was encountered with tortuous, elongated, torsional splenic pedicle and a single dense adhesive band with descending colon. Splenectomy was offered to the patient. Post-operatively, the patient is healthy and symptom free at one-year follow-up. The rare clinical diagnosis of this condition, particularly in the paediatric age-group, makes it an enigma for the surgical world.

Introduction

Wandering spleen (WS), is a rare clinical condition, with only about 500 cases reported worldwide and an incidence rate of 0.2% [ 1 , 2 ]. One of the first documented descriptions of WS came from Dr Josef Dietl, a Polish clinician, who not only documented three cases between 1854 and 1863 but also described the laxity of splenic ligaments as the likely etiology [ 2 ]. Among the various hypotheses proposed, laxity of the spleen’s supporting ligaments is the most agreed upon. The condition leads to migration of the spleen from its normal position in the left hypochondrium to the pelvic or iliac region. This migration in turn often leads to torsion of the elongated splenic pedicle, which makes the patient symptomatic. WS is usually seen in women of child-bearing age, and the condition is particularly rare in the paediatric population [ 3 ]. We present one such rare case of a WS in a child who presented with intermittent abdominal pain that was clinically and radiologically confirmed as WS with splenic infarction. The patient was offered a splenectomy.

Case Presentation

An 11-year-old girl presented to us with repeated episodes of intermittent, moderate-to-severe intensity, non-radiating pain in the right iliac fossa for the last six months. She had no history of fever, vomiting or urinary symptoms. On physical examination, a 10 x 4 cm intra-abdominal, ballotable, smooth-surfaced lump, which had restricted mobility with respiration, was palpated in the left iliac fossa. Her routine haematological and biochemical investigations were within normal limits. Abdominal sonography, and colour Doppler flow imaging revealed a 13 x 15 cm spleen with heterogeneous echogenicity, situated antero-inferior to the left kidney in the left iliac fossa with tortuous, elongated splenic vessels with torsion and a low blood-flow profile. Contrast-enhanced CT of the abdomen revealed a 15 x 17 cm spleen in the left iliac fossa, with a long, tortuous pedicle (approximately 15 cm) with torsion and focal areas of splenic parenchymal ischemia ( Figure 1 ).

Contrast-enhanced CT images of abdomen. (A) Coronal reformatted image shows that the spleen has migrated from the left hypochondrium and is ectopically located in the left lumbar and iliac region (marked with an arrow). (B) Sagittal reformatted image shows that the spleen is located inferior to the left kidney.

The patient was scheduled for an elective splenectomy and was immunized against Hae mophilus influenza e , pneumococcus and meningococcus as per the protocol. Intraoperatively, the spleen was found in the left iliac region, antero-inferior to the left kidney. There was a dense band between the splenic hilum and descending colon, which was probably responsible for the restricted mobility of the spleen during clinical examination. A long splenic pedicle with torsion was also found. The spleen showed multiple areas of infarction. ( Figure 2 ). Keeping in view the above findings, a splenectomy was performed. The histopathological report inferred that there were several areas of extensive splenic haemorrhage and infarction with neutrophilic infiltration of the splenic vessel walls. The postoperative period has been uneventful, and the patient has been healthy and symptom free at her one-year follow-up.

Intra-operative findings. (A) The splenic vascular pedicle with torsion (marked by an arrow). (B) The dense band connecting splenic hilum with descending colon (marked by an arrow) with areas of splenic infarction.

Among all the solid organs in the human body, the spleen is possibly the least understood and the most discredited. Our medical knowledge on the spleen has come a long way from the days when it was considered to be the seat of laughter, associated with black bile and credited with disharmony of life, to the present day concept in which it is recognized as an important reticuloendothelial organ [ 4 ].

WS is a rare clinical facet of this organ, which was first described by Von Horne in 1667 [ 5 ]. WS is defined as the condition in which the spleen migrates from its normal position in the left hypochondrium, mostly likely due to an error in the embryological development of the primary supporting ligament of spleen with elongation of its vascular pedicle. The credit for documenting the first case of this condition goes to the Polish clinician, Dr Jozef Dietl. He not only prognosticated the life-threatening complications of this condition, he also predicted that hypoplasia of splenic ligaments was probably the major culprit [ 2 ].

Anatomically, the spleen has six peritoneal attachments (primary suspensory ligaments) that are directly associated with it (gastrosplenic, splenorenal, splenophrenic, splenocolic, pancreaticosplenic and presplenic folds) and two ligaments (pancreaticocolic and phrenicocolic) in indirect association. Failure of fusion of the dorsal mesogastrium to the posterior abdominal wall during embryogenesis leads to failure or defective attachment of these ligaments, leading to WS. The gastrosplenic, splenorenal and phrenicocolic ligaments have been primarily implicated ( Figure 3 ) [ 6 ].

Diagram depicting the suspensory ligaments of the spleen. The three suspensory ligaments usually implicated in the development of wandering spleen are (i) the gastrosplenic ligament, (ii) the splenorenal ligament and (iii) the phrenicocolic ligament.

A second school of thought incriminates the hormonal changes and abdominal laxity in multiparous women as an acquired cause of WS and better explains the presence of WS in women of child-bearing age [ 7 ]. Huge, heavy spleens due to malaria, infectious mononucleosis and benign haematologic diseases have also been implicated in the literature [ 8 ].

The abnormal fixation of the spleen predisposes the splenic vascular pedicle to become tortuous, elongated and prone to intermittent torsion, in turn making the spleen vulnerable to infarction [ 3 ].

Often labelled as a rare clinical diagnosis, especially in the paediatric population, the presentations of WS can be vivid [ 9 ]. The spectrum can range from an asymptomatic abdominal mass, an incidental finding on routine abdominal sonography, intermittent abdominal pain (as in our patient) and splenomegaly to severe abdominal pain and discomfort due to torsion of the splenic vascular pedicle.

Clinically, a mobile mass can be felt on abdominal examination. However, in our case the presence of a dense band between the spleen and descending colon restricted the mobility of the spleen. A sonographic examination of the abdomen usually suffices to delineate the location, size and any architectural deformities of the spleen in most cases. When the splenic vascularity is in question, either colour Doppler flow imaging or contrast-enhanced CT can both confirm the diagnosis and provide additional information on the blood flow profile in the splenic pedicle. Splenic parenchymal ischemia is characterized by a change in blood flow and a heterogeneous echogenicity of the spleen. This information plays a vital role in the pre-operative decision to offer the patient splenoplexy or splenectomy as the choice of surgery.

The surgical intervention is defined by the vascularity of the spleen. A patient with splenic infarction due to torsion of the splenic pedicle, as in our case, is offered splenectomy. Splenoplexy, either open or laparoscopic, is offered to most of the other patients in whom splenic pedicle detorsion and splenic fixation to either the diaphragm or abdominal wall are done [ 9 ]. Nonoperative management of a WS is not advised as there is a 65% chance of torsion with ischemic splenic infarction without fixation of the spleen [ 10 ].

WS is a rare condition that often presents as a clinical enigma. A clinician should have a high degree of suspicion for WS, particularly in women of child-bearing age and children who present with recurrent abdominal pain and a mobile abdominal mass. Modern imaging techniques are usually diagnostic and can identify the splenic pedicle torsion with a high degree of accuracy. Surgical intervention, in the form of either splenoplexy or splenectomy, is largely governed by the findings of pedicle torsion and the associated risk for acute splenic infarction.

Conflict of interest statement : none declared.

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Citation, DOI, disclosures and article data

At the time the article was created Elena Trajcevska had no recorded disclosures.

At the time the article was last revised Mohammad Taghi Niknejad had no financial relationships to ineligible companies to disclose.

• Floating spleen
• Splenic ptosis
• Ectopic spleen
• Splenoptosis
• Drifting spleen
• Systopic Spleen
• Displaced spleen

Wandering spleen is a rare condition in which the spleen migrates from its usual anatomical position, commonly to the lower abdomen or pelvis.

On this page:

Epidemiology, clinical presentation, radiographic features, treatment and prognosis.

• Related articles
• Cases and figures

Wandering spleen is rare, with a reported incidence of <0.5%.

Diagnosis is most commonly made between the ages of 20-40 years and is more common in multiparous women 1,6 .

A wandering spleen can be an elusive diagnosis as its presentation is greatly variable and intermittent torsion can cause non-specific signs and symptoms.

It can present as an asymptomatic or painful abdominal mass, intermittent abdominal pain, or as an acute abdomen (e.g.  bowel obstruction , acute pancreatitis ) 3,4,6 .

The abnormal mobility of the spleen is caused by an abnormality of its suspensory ligaments. There may be a congenital absence or underdevelopment of these ligaments, or an acquired laxity of the ligaments caused by various conditions, such as pregnancy or diseases causing splenomegaly . Due to these abnormal ligaments, a long vascular pedicle may form, containing the splenic vessels, predisposing the spleen to torsion and consequently splenic infarction   4 .

There are various causes, mostly related to splenomegaly .

• sickle cell disease
• heterotaxy syndrome
• lymphoproliferative disease
• mononucleosis

The often non-specific clinical presentation of a wandering spleen makes radiological evaluation invaluable in its diagnosis. Performing the radiological investigations in different positions allows identification of the wandering spleen’s inclination to wander.

Plain radiograph

A wandering spleen is not frequently diagnosed on plain film radiography, but findings on abdominal x-ray may include 3,6 :

• absence of splenic shadow in the left upper quadrant
• space-occupying soft tissue mass in an abnormal location
• distended bowel loops

Can be used to identify an abnormal anatomical position of the spleen, usually low-lying, or an absence of the spleen in the left upper quadrant 3,5 . It has been described that the mobility of the spleen can be demonstrated when scanning in the right decubitus position, with the migration of the spleen to the dependent position on the right side 6 . There may also be a finding of a characteristic comma-shaped spleen in an extra-anatomical position 4 .

Doppler ultrasound

Doppler ultrasound can demonstrate the vascular flow to the spleen and help diagnose splenic torsion or infarction 6 .

CT with contrast can be useful in identifying the displaced spleen and demonstrating the degree of organ ischemia in the setting of torsion and infarction of the spleen 1 .

Possible findings include 4,5,7 :

• absence of the spleen in the left upper quadrant
• ovoid or comma-shaped abdominal mass
• whirl sign : a whirled appearance of hyperdense, non-enhancing splenic vessels
• enlarged spleen, with minimal or no enhancement
• signs of splenic hypoperfusion: heterogeneous, capsular (rim-like) or globally decreased enhancement

Nuclear medicine

Technetium sulfur colloid liver-spleen scan can be used to identify an abnormal abdominal mass as the spleen 1 .

A wandering spleen is treated surgically, ideally by detorsion and splenopexy. However, if there is evidence of hypersplenism , thrombosis , or infarction , splenectomy may be necessary. Laparoscopic techniques for both splenopexy and splenectomy are preferred, as they offer the benefits of minimally invasive surgery 2-4 .

• 1. Wallace S, Herer E, Kiraly J, Valikangas E, Rahmani R. A Wandering Spleen: Unusual Cause of a Pelvic Mass. Obstet Gynecol. 2008;112(2 Pt 2):478-80. doi:10.1097/AOG.0b013e3181809671 - Pubmed
• 2. Magowska A. Wandering Spleen: A Medical Enigma, Its Natural History and Rationalization. World J Surg. 2013;37(3):545-50. doi:10.1007/s00268-012-1880-x - Pubmed
• 3. Lebron R, Self M, Mangram A, Dunn E. Wandering Spleen Presenting as Recurrent Pancreatitis. JSLS. 2008;12(3):310-3. PMC3015861 - Pubmed
• 4. Bouassida M, Sassi S, Chtourou M et al. A Wandering Spleen Presenting as a Hypogastric Mass: Case Report. Pan Afr Med J. 2012;11:31. PMC3325069 - Pubmed
• 5. Raissaki M, Prassopoulos P, Daskalogiannaki M, Magkanas E, Gourtsoyiannis N. Acute Abdomen Due to Torsion of Wandering Spleen: CT Diagnosis. Eur Radiol. 1998;8(8):1409-12. doi:10.1007/s003300050562 - Pubmed
• 6. Taori K, Sanyal R, Deshmukh A, Saini T. Pseudocyst Formation: A Rare Complication of Wandering Spleen. Br J Radiol. 2005;78(935):1050-2. doi:10.1259/bjr/33073529 - Pubmed
• 7. Lam Y, Yuen K, Chong L. Acute Torsion of a Wandering Spleen. Hong Kong Med J. 2012;18(2):160-2. - Pubmed
• 8. Yildiz A, Ariyurek M, Karcaaltincaba M. Splenic Anomalies of Shape, Size, and Location: Pictorial Essay. The Scientific World Journal. 2013;2013:1-9. doi:10.1155/2013/321810 - Pubmed

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• superior gluteal nerve
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• perineal branch
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Charles Baudelaire's Fleurs du mal / Flowers of Evil

Quand le ciel bas et lourd pèse comme un couvercle Sur l'esprit gémissant en proie aux longs ennuis, Et que de l'horizon embrassant tout le cercle II nous verse un jour noir plus triste que les nuits;

Quand la terre est changée en un cachot humide, Où l'Espérance, comme une chauve-souris, S'en va battant les murs de son aile timide Et se cognant la tête à des plafonds pourris;

Quand la pluie étalant ses immenses traînées D'une vaste prison imite les barreaux, Et qu'un peuple muet d'infâmes araignées Vient tendre ses filets au fond de nos cerveaux,

Des cloches tout à coup sautent avec furie Et lancent vers le ciel un affreux hurlement, Ainsi que des esprits errants et sans patrie Qui se mettent à geindre opiniâtrement.

— Et de longs corbillards, sans tambours ni musique, Défilent lentement dans mon âme; l'Espoir, Vaincu, pleure, et l'Angoisse atroce, despotique, Sur mon crâne incliné plante son drapeau noir.

— Charles Baudelaire

When the low, heavy sky weighs like a lid On the groaning spirit, victim of long ennui, And from the all-encircling horizon Spreads over us a day gloomier than the night;

When the earth is changed into a humid dungeon, In which Hope like a bat Goes beating the walls with her timid wings And knocking her head against the rotten ceiling;

When the rain stretching out its endless train Imitates the bars of a vast prison And a silent horde of loathsome spiders Comes to spin their webs in the depths of our brains,

All at once the bells leap with rage And hurl a frightful roar at heaven, Even as wandering spirits with no country Burst into a stubborn, whimpering cry.

— And without drums or music, long hearses Pass by slowly in my soul; Hope, vanquished, Weeps, and atrocious, despotic Anguish On my bowed skull plants her black flag.

— William Aggeler, The Flowers of Evil (Fresno, CA: Academy Library Guild, 1954)

When the cold heavy sky weighs like a lid On spirits whom eternal boredom grips, And the wide ring of the horizon's hid In daytime darker than the night's eclipse:

When the world seems a dungeon, damp and small, Where hope flies like a bat, in circles reeling, Beating his timid wings against the wall And dashing out his brains against the ceiling:

When trawling rains have made their steel-grey fibres Look like the grilles of some tremendous jail, And a whole nation of disgusting spiders Over our brains their dusty cobwebs trail:

Suddenly bells are fiercely clanged about And hurl a fearsome howl into the sky Like spirits from their country hunted out Who've nothing else to do but shriek and cry —

Then long processions without fifes or drums Wind slowly through my soul. Hope, weeping, bows To conquest. And atrocious Anguish comes To plant his black flag on my drooping brows.

— Roy Campbell, Poems of Baudelaire (New York: Pantheon Books, 1952)

When the Low, Heavy Sky

When the low, heavy sky weighs like the giant lid Of a great pot upon the spirit crushed by care, And from the whole horizon encircling us is shed A day blacker than night, and thicker with despair;

When Earth becomes a dungeon, where the timid bat Called Confidence, against the damp and slippery walls Goes beating his blind wings, goes feebly bumping at The rotted, moldy ceiling, and the plaster falls;

When, dark and dropping straight, the long lines of the rain Like prison-bars outside the window cage us in; And silently, about the caught and helpless brain, We feel the spider walk, and test the web, and spin;

Then all the bells at once ring out in furious clang, Bombarding heaven with howling, horrible to hear, Like lost and wandering souls, that whine in shrill harangue Their obstinate complaints to an unlistening ear.

— And a long line of hearses, with neither dirge nor drums, Begins to cross my soul. Weeping, with steps that lag, Hope walks in chains; and Anguish, after long wars, becomes Tyrant at last, and plants on me his inky flag.

— Edna St. Vincent Millay, Flowers of Evil (NY: Harper and Brothers, 1936)

when low skies weightier than a coffin-lid cast on the moaning soul their weary blight, and from the whole horizon's murky grid its grey light drips more dismal than the night;

when earth's a dungeon damp whose chill appals, in which — a fluttering bat — my Hope, alone buffets with timid wing the mouldering walls and beats her head against the dome of stone;

when close as prison-bars, from overhead, the clouds let fall the curtain of the rains, and voiceless hordes of spiders come, to spread their infamous cobwebs through our darkened brains,

explosively the bells begin to ring, hurling their frightful clangour toward the sky, as homeless spirits lost and wandering might raise their indefatigable cry;

and ancient hearses through my soul advance muffled and slow; my Hope, now pitiful, weeps her defeat, and conquering Anguish plants his great black banner on my cowering skull.

— Lewis Piaget Shanks, Flowers of Evil (New York: Ives Washburn, 1931)

When the low heavy sky weighs like a lid Upon the spirit aching for the light, And all the wide horizon's line is hid By a black day sadder than any night;

When the changed earth is but a dungeon dank Where batlike Hope goes blindly fluttering And, striking wall and roof and mouldered plank, Bruises his tender head and timid wing;

When like grim prison-bars stretch down the thin, Straight, rigid pillars of the endless rain, And the dumb throngs of infamous spiders spin Their meshes in the caverns of the brain; —

Suddenly, bells leap forth into the air, Hurling a hideous uproar to the sky As 'twere a band of homeless spirits who fare Through the strange heavens, wailing stubbornly.

And hearses, without drum or instrument, File slowly through my soul; crushed, sorrowful, Weeps Hope, and Grief, fierce and omnipotent, Plants his black banner on my drooping skull.

— Jack Collings Squire, Poems and Baudelaire Flowers (London: The New Age Press, Ltd, 1909)

When the low and heavy sky presses like a lid On the groaning heart a prey to slow cares, And when from a horizon holding the whole orb There is cast at us a dark sky more sad than night;

When earth is changed to a damp dungeon, Where Hope, like a bat, Flees beating the walls with its timorous wings, And knocking its head on the rotting ceilings;

When the rain spreads out vast trails Like the bars of a huge prison, And when, like sordid spiders, silent people stretch Threads to the depths of our brains,

Suddenly the bells jump furiously And hurl to the sky a horrible shriek, Like some wandering landless spirits Starting an obstinate complaint.

— And long hearses, with no drums, no music, File slowly through my soul: Hope, Conquered, cries, and despotic atrocious Agony Plants on my bent skull its flag of black.

— Geoffrey Wagner, Selected Poems of Charles Baudelaire (NY: Grove Press, 1974)

Two editions of Fleurs du mal were published in Baudelaire's lifetime — one in 1857 and an expanded edition in 1861. "Scraps" and censored poems were collected in Les Épaves in 1866. After Baudelaire died the following year, a "definitive" edition appeared in 1868.

• 1857 Fleurs du mal First edition with 100 poems
• 1861 Fleurs du mal Second edition missing censored poems but including new ones
• 1866 Les Épaves Twenty-three "scraps" including the poems censored from the first edition
• 1868 Fleurs du mal Comprehensive edition published after Baudelaire's death
• All Poems (Alphabetical) Every poem from each edition
• Audio Readings of Baudelaire mostly in French
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