Incidentally discovered asymptomatic splenic hamartoma misdiagnosed as an aneurysm: A case report

BACKGROUNDSplenic hamartoma (SH) is a rare, benign vascular proliferation that is often found incidentally. It may be misdiagnosed as a splenic aneurysm or splenic malignancy.CASE SUMMARYA 21-year-old male patient was admitted to our hospital with a complaint of an incidentally discovered asymptomatic splenic space-occupying lesion for 2 wk. Abdominal computed tomography (CT) scan showed a circular low-density shadow in the hilum of the spleen. Contrast-enhanced CT revealed an aneurysm located in the hilum of the spleen before operation. Laparoscopic splenectomy was performed and postoperative pathology revealed the presence of SH.CONCLUSIONImaging studies are insufficient for the differential diagnosis of SH from other diseases, and laparoscopic splenectomy is a less invasive procedure and useful for the diagnostic purpose as well.     

Multidetector-Row Computed Tomography Imaging of Splenic Trauma

The spleen is the intra-abdominal organ most often injured as a result of blunt trauma. Multidetector-row computed tomography (MDCT) plays an important role in the detection and characterization of splenic injury. It has been shown to be highly accurate and can detect splenic vascular lesions, the presence of which has been shown to be a predictor of failure of nonoperative management. The increased use of angiography and splenic artery embolization in the management of such injuries has led to improved success rates with nonoperative management. This article reviews the various appearances of the injured spleen and discusses the use of MDCT in the initial evaluation of injury. The indications for angiography and embolization are reviewed, with examples of appearances of the postembolization spleen.     

Splenic tumour: a clinicopathological study

Splenic tumours are occasionally found during routine physical check-ups or elective abdominal image studies. Histologically, most splenic tumours are of benign vascular origin. To avoid unnecessary surgery for asymptomatic patients with benign splenic tumours and clarify the clinicopathological features of spleen tumours, this study gathered 44 cases of primary or isolated metastatic spleen tumours confirmed by pathology from surgery specimens or biopsies. The differences in clinicopathological features and image presentations between benign and malignant spleen tumour were investigated. Thirty-two cases involved benign tumours while 12 cases were malignant. Among the benign tumours, vascular originating tumours were most common (with 14 cases of cavernous haemangiomas, 13 cases of lymphangioma, three cases of lymphangiohaemangioma and one case of Littoral cell angioma). Notably, one, case of inflammatory pseudotumour because of Schistosoma parasite infection was also noted. Among the malignant tumours, there were four cases of angiosarcomas with vascular endothelium origins, as well as lymphomas and six metastatic tumours. Image studies were non-specific. Image study alone is an inadequate basis for making differential diagnoses between benign and malignant tumours. Instead, pathological studies are required for a final diagnosis. Using previous studies and this investigation, fine needle aspiration biopsy of spleen tumours with the help of ultrasonic or computed tomography appears a safe and effective method for obtaining biopsy specimens. Splenectomy is recommended only for patients with malignancies or complications such as intractable abdominal pain, coagulopathy or tumour rupture with an unstable haemodynamic state.     

Urgent laparoscopic mesh splenopexy for torsion of wandering spleen and distal pancreas: A case report

Wandering spleen is a condition in which an incomplete fusion of the splenic ligaments allows the spleen to move within the abdomen, predisposing it to splenic torsion along its vascular pedicle. Torsion of a wandering spleen is an uncommon occurrence, especially in children, and associated torsion of the distal pancreas is even more unusual, with only four cases having been reported in adults. Non‐specific clinical presentation makes radiologic evaluation essential in order to obtain a diagnosis and to send the patient for early surgery before life‐threatening complications arise. Here we present a rare case of torsion of wandering spleen together with volvulus of the distal pancreas in a 13‐year‐old girl. In this case, prompt radiological assessment allowed for an early diagnosis, and the patient was successfully treated with urgent laparoscopic derotation of both the spleen and the distal pancreas as well as mesh splenopexy. To the best of our knowledge, this procedure has never been described in a pediatric setting.     

Splenic hamartoma: A case report and review of the literature

Splenic hamartoma is a rare benign malformation, composed of an anomalous mixture of normal splenic elements, often found incidentally while working up other complaints or at autopsy. A splenic mass was incidentally found while evaluating the effects of a traffic accident in a 63-year-old woman. Abdominal computed tomography revealed a well-defined splenic mass with rim enhancement. The patient underwent splenectomy. The resected spleen contained a well-defined mass lesion measuring 3.5 cm × 3.0 cm. Microscopic examination revealed disorganized slit-like vascular channels lined by plump endothelial cells without atypia. The cells lining the vascular channels were positive for CD8, CD31, CD34 and vimentin. Endothelial cells that are positive for CD8 are a key feature that differentiates hamartoma from other vascular lesions of the spleen. Although this tumor is very rare, it must be included in the differential diagnosis of splenic mass-forming lesions.     

Splenic volvulus of a wandering spleen

BackgroundWandering spleen is a rare condition in which the spleen is not anchored properly, due to congenital or acquired weakness of the splenic ligaments. This allows the spleen to migrate to any portion of the abdomen or pelvis, and can cause complications, including a splenic volvulus. The presentation of splenic volvulus of a wandering spleen ranges from mild pain to a surgical emergency. Splenic volvulus of a wandering spleen can cause significant morbidity and mortality, and often warrants surgical intervention. Cases of splenic volvulus of a wandering spleen have been reported in radiology and surgery literature, however there are no reports in emergency medicine literature in North America.Case reportA 37-year-old female presented to the ED with seven days of mild left upper quadrant abdominal pain that acutely worsened. She underwent laboratory studies which were near her baseline values. A CT abdomen pelvis demonstrated findings consistent with splenic volvulus of a wandering spleen. She was taken emergently to the operating room for exploratory laparotomy, detorsion of spleen, and splenectomy. Her postoperative course was uneventful and she was discharged on hospital day six.Splenic volvulus of a wandering spleen is rare, though carries significant morbidity and mortality, especially if unrecognized. The presentation of splenic volvulus is variable, ranging from minor symptoms to an acute abdomen. Early diagnosis can prevent downstream complications, including development of vascular congestion, ischemia or infarcted intra-abdominal organs. Emergency Physicians should consider splenic volvulus in the differential diagnosis as an etiology of left-sided abdominal pain.     

Multiple Lesions of the Spleen: Differential Diagnosis of Cystic and Solid Lesions

Lesions in the spleen may be encountered in a variety of clinical settings ranging from asymptomatic patients to patients who are critically ill. Etiologies for multifocal splenic lesions include infectious and inflammatory processes, primary vascular and lymphoid neoplasms, metastatic disease, vascular processes, and systemic diseases. There is often overlap in the imaging appearance alone, so the clinical setting is very helpful in differential diagnosis. In the immunocompromised patient, multiple small splenic lesions usually represent disseminated fungal disease and microabscesses. The spleen is a relatively rare site for metastatic disease; patients with metastatic lesions in the spleen usually have disease in other sites as well. Breast, lung, ovary, melanoma, and colon cancer are common primary tumors that metastasize to the spleen. Vascular neoplasms of the spleen represent the majority of the nonhematologic/nonlymphoid neoplasms and commonly produce multifocal lesions. Splenic infarcts may be seen with localized processes such as portal hypertension or pancreatitis, or may arise from an embolic source. Radiologists should be aware of the spectrum of processes that may involve the spleen and the clinical context in which they occur.     

Mass at the splenic hilum: a clue to torsion of a wandering spleen located in a normal left upper quadrant position.

Wandering spleen is an extremely rare condition in which the spleen is lacking its normal ligamentous attachments and therefore can move to an ectopic position in the abdomen or pelvis. Wandering spleen predisposes the patient to life-threatening complications due to torsion of the spleen's vascular pedicle, with resulting splenic infarction, portal hypertension, and bleeding. Because of the nonspecific symptoms, imaging plays an important role. To our knowledge, only a few case reports describing wandering spleen in the pediatric population have been published, including 2 cases in infancy. We report a case of splenic torsion in an infant with a preoperative diagnosis made on the basis of color and power Doppler sonography. The diagnosis was confirmed by contrast-enhanced helical computed tomography (CT) and proved at surgery. On sonography, a diffusely hypoechoic spleen and a mass at the splenic hilum representing the torsed splenic pedicle were shown. The splenic hilar mass correlates with the CT "whirl" sign indicative of torsion.     

Contrast-Enhanced Sonography of the Spleen

Sonography is frequently the first imaging modality employed to evaluate the spleen. Nevertheless, splenic abnormalities frequently determine subtle changes in echogenicity and may be overlooked. Additionally, splenic disorders have a nonspecific appearance, mostly appearing as hypoechoic defects. Difficulties in differential diagnosis are not uncommon, with splenic infarctions resembling, for example, focal lesions. Color Doppler is usually of limited additional value. Instead, the spleen is optimally suited for contrast-enhanced sonography, being superficial, small, and homogeneous, and showing intense and persistent contrast enhancement. Scarcely evident abnormalities become evident after contrast medium injection. Additional information can be obtained in many clinical scenarios, including blunt trauma, left flank pain, lymphoma, and incidental detection of splenic abnormalities.     

Littoral cell angioma: A case report

Primary splenic lesions are rare entities among which littoral cell angioma(LCA) is a recently described, uncommon vascular lesion that is unique to the spleen. It has heretofore been described primarily in pathologic series and has been found mostly to behave as a benign entity. A few reports of malignant variants have been reported. We present a case report of a solitary LCA discovered after splenectomy for an incidentally discovered splenic lesion, along with a literature review.     

A rare case of non-traumatic intrasplenic pseudoaneurysms in a patient with acute T-cell lymphoblastic leukemia

Pseudoaneurysm (PSA) or false aneurysm is a vascular lesion resulting from a focal and incomplete rupture of the arterial wall (intimate and/or elastic lamina), that allows blood to escape into the arterial wall; this small contained break causes a contained collection of blood and the creation of a “new” less resistant vessel wall, consisting of adventitia and perivascular tissues. Intrasplenic pseudoaneurysms are rare and more frequently recognize traumatic origin, sometimes are also unexpected lesions due to non-recent trauma. In contrast, non-traumatic intrasplenic pseudoaneurysms are rare complications usually due to splenic infarction, infiltration by malignant systemic disorders, infectious process, chronic pancreatitis, and arteritis. Both traumatic and non-traumatic PSA are potentially life threatening, known to cause spontaneous rupture of the spleen with massive hemoperitoneum. Contrast-enhanced CT is the gold standard technique to detect splenic PSA; however, it is important to know how to recognize it also with other imaging methods such as with ultrasound (US) and contrast-enhanced ultrasound (CEUS). US and CEUS can be often the first-line diagnostic techniques and allow to detect these lesions; they are also very useful in the follow-up. Our case report can be a reminder of the utility of the US and CEUS in detecting splenic pseudoaneurysms, which are potentially a life-threatening complication; we also recall the semiotics of these lesions with baseline ultrasound (US), color Doppler US and contrast-enhanced ultrasound (CEUS). Then, we highlight the role of contrast-enhanced CT in confirming the diagnosis and we report about the diagnostic and therapeutic value of angiography. We have to think about the possibility of a pseudoaneurysm even in the absence of a recent trauma, associated with other conditions such as a lymphoproliferative disease.     

Role of Doppler sonography in the evaluation of accessory spleens after splenectomy.

OBJECTIVE: Splenectomy influences the Doppler blood flow pattern in the splenic artery. Blood flow in this vessel might return to normal if an accessory spleen increases in size after splenectomy. Our objective was to evaluate the resistive index of the splenic artery depending on the presence or absence of a hypertrophic accessory spleen in splenectomized patients. METHODS: The resistive index of the splenic artery was evaluated by duplex Doppler sonography in 19 splenectomized patients (8 with a hypertrophic accessory spleen) and in 8 healthy volunteers. The resistive index was measured within 3 cm of the origin of the splenic artery, and 3 different measurements were averaged. The presence or absence of a hypertrophic accessory spleen was diagnosed on the basis of sonography, computed tomography, magnetic resonance imaging, or scintigraphy, as well as by the presence or absence of Howell-Jolly bodies on a peripheral blood smear. RESULTS: The resistive index of the splenic artery in the splenectomized patients without a hypertrophic accessory spleen (mean +/- SD, 0.82 +/- 0.06; n = 11) was significantly (P < or = .0001) higher than in splenectomized patients with a hypertrophic accessory spleen (0.63 +/- 0.06; n = 8) and in control subjects (0.63 +/- 0.05; n = 8). CONCLUSIONS: In the splenectomized patient, a hypertrophic accessory spleen is associated with a normal resistive index in the splenic artery.     

Sonographic measurements of the fetal spleen: clinical implications

Normal values for fetal spleen dimensions are proposed, including longitudinal, coronal, and transverse diameters, the perimeter, and the estimated volume. Similar values were then obtained in cases of Rh-immunization and prolonged premature rupture of the membranes. A good correlation between amniotic fluid optical density and fetal spleen size was found. Only severely affected fetuses showed splenic values above the upper limit. Since sonographic examination can be regarded as a reliable method, nomograms can be useful in detecting growth disorders of the fetal spleen and thus provide a new complementary method to identify possible fetal diseases of genetic disorders.     

慢性病毒性肝炎G/S分期与脾脏指标的关系

目的探讨慢性病毒性肝炎不同G/S分期与脾脏指标的关系。方法361例慢肝患者根据肝穿结果分为无肝纤维化(S0)到肝硬化(S4)五期,按炎症分为Gl～G4四级。对照组104例为体检健康者。比较慢肝组与对照组之间以及慢肝不同G/S分期之间脾脏指标的差异。结果慢肝组与对照组脾脏大小、脾动静脉内径以及脾血流量差异有显著性,且慢肝组均大于对照组;G分期之间脾脏大小、脾静脉内径以及脾动脉最大速度差异有显著性,且随G分期增高而增大;S分期之间脾脏大小、脾静脉内径与流速、脾动脉阻力指数差异有显著性;不同炎症活动度之间脾脏大小、脾静脉内径以及脾动脉最大速度差异有显著性,且随炎症程度越重诸数值越大;脾脏厚度与脾静脉内径及血流量的相关系数分别为0.510、0.447。结论慢肝患者脾脏增大,脾动静脉内径增宽,脾血流量增多,且随G/S分期增高而增高。脾脏大小、脾动静脉内径以及血流动力学指标有助于判断病情。     

Splenic lymphangioma: US and CT diagnosis and clinical manifestations

BACKGROUND AND METHODS: We tried to determine the role and problems of gray-scale sonography (US), computed tomography (CT), and color Doppler sonography in the diagnosis of splenic lymphangioma on the basis of our experience with seven adult cases with this relatively rare tumor. RESULTS: (1) The whole spleen was replaced by a collection of cysts of different sizes with or without calcifications in six patients. In these patients, color Doppler sonography showed the intrasplenic arteries and veins running along the cyst walls. (2) The enlarged spleen occupied the whole upper abdomen and contained numerous small cysts in one patient. The patient was initially diagnosed as having a pancreatic tumor because of the location, but color Doppler sonography clearly demonstrated two vessels (artery and vein) running parallel from the center of the mass. This characteristic vascular structure led to the determination that the mass was the markedly enlarged spleen. (3) The splenic lesion was isolated in six patients but was associated with mesenteric and pleural lymphangioma in one symptomatic patient. CONCLUSIONS: (1) When US shows multiple cysts of different sizes in the spleen, the diagnosis of splenic lymphangioma is not difficult to make with US and CT alone. (2) Color Doppler sonography is a very useful tool to increase diagnostic confidence because it demonstrates the vasculature of the mass. (3) When examining patients with splenic lymphangioma, one should consider the possibility of multiorgan involvement.     

Angiosarcoma of the spleen with consumption coagulopathy

A female patient with intravitally diagnosed splenic angiosarcoma is described. Progress of the cancerous process was attended by the development of consumption coagulopathy with profound fibrinogenopenia and thrombocytopenia. In this case the DIC syndrome was characterized by the lack of systemic fibrinolysis activation. The rupture of the cavernous tumor of the spleen and profound disorders of hemostasis determined profuse intraperitoneal hemorrhage and the patient's death. Diagnostic criteria that contribute to early recognition of splenic angiosarcoma are suggested.     

Splenic haemodynamics and portal hypertension in patients with liver cirrhosis and spleen enlargement

Summary. The relationships between portal hypertension and spleen enlargement, in patients with liver cirrhosis, are not clearly defined; as well as those between splenic haemodynamics and portal hypertension. In 25 cirrhotics with spleen enlargement and portal hypertension and in seven controls, the following parameters were determined: estimated splenic volume (ESV) from the radiographic view of the spleen, according to Blendis, Williams and Kreel (1969), specific splenic blood-flow (SSBF), total splenic blood-flow (TSBF), porto-hepatic gradient (PHG), specific splenic resistance (SSR) and total splenic resistance (TSR). Moreover, the size and extension of oesophageal varices, at oesophagoscopy, were classified according to Dagradi (1973). PHG, ESV and TSBF were increased in all subjects, SSBF was increased in two cases, SSR was increased in two cases and decreased in two cases, TSR was decreased in all cases and ESV was not correlated to the level of portal hypertension. Neither TSBF nor TSR were found to be correlated to the level of portal hypertension, as estimated by PHG or by oesophageal varices. It is concluded that, in patients with liver cirrhosis and spleen enlargement, splenomegaly is likely to be the consequence of pulp hyperplasia and not of passive congestion, and that increases in splenic blood-flow do not contribute significantly to portal hypertension.     

超声显像对脾组织块自体移植术后的随防

目的 探讨超声显像对脾组织块自体移植术后的随防的价值。方法 本组脾切除术后脾组织块自体移植术后10例,超声均测及脾块,经免疫学检查结果证实存活。结果 脾块均位于腹腔浅表部位,声像图特征:(1)脾组织块回声与正常脾相以,呈均匀低回声;(2)脾块包膜回声增厚;(3)长时间观察无变化。免疫学中,进行IgG、A、M、及C3测定,发现上述指标逐步升高,直至恢复正常,血常规正常,血中未发现Howell-Jolly小体及空泡红细胞。结论 超声显像可替代其他影像诊断方法,显示脾组织块。     

彩超对特发性血小板减少紫癫及门脉高压合并脾功能亢进行脾动脉栓塞术前后的评价

目的观察特发性血小板减少性紫癫(ITP)患者和门静脉高压合并脾功能亢进(脾亢)患者行脾动脉栓塞术前后脾脏及脾静脉血流动力学及血常规主要检验指标变化。方法应用彩色多普勒超声检测12例ITP患者和22例门静脉高压合并脾亢患者行脾动脉栓塞术前后脾脏及脾静脉管径、血流速度、血流量的对比变化。结果脾动脉栓塞术后两组患者脾静脉管径缩小(P<0.01),脾静脉平均血流速度降低(P<0.01),脾静脉血流量明显减少(P<0.01)。脾动脉栓塞术后可见脾实质内梗塞坏死灶的回声。34例脾动脉栓塞术后血小板数量均有明显增加(P<0.01)。结论彩色多普勒超声可以直观脾实质的二维超声图像变化,准确分析脾动脉栓塞术前后脾静脉的血流动力学改变,且脾静脉回流量减少与梗塞面积呈正相关。可对脾动脉栓塞术的疗效进行有效地评估。