Unusual Causes of Abdominal Pain, #4

Unusual Causes of Abdominal Pain

Unusual Causes of Abdominal Pain

CASE

A 4 year old female was referred to the pediatric gastroenterology clinic with intermittent postprandial nausea and abdominal pain with varying location. The episodes, each lasting 3-5 days, have occurred several times over the past couple of years and have gradually worsened over the past few months. The parents deny that she vomits old food. Chart review reveals a waxing and waning presence of splenomegaly on abdominal exam. Prior workup by her pediatrician included a normal complete blood count (CBC) and rapid streptococcus test. Epstein-Barr virus (EBV) titers demonstrated prior infection, but were not consistent with current infection. Splenic ultrasound demonstrated an 11.2 cm spleen (normal < 9 cm) with no other focal abnormality noted. On presentation, physical examination revealed a soft, non-tender, non-distended abdomen with bowel sounds appreciated in all four quadrants. Her spleen was located in left lower quadrant. She was then sent for a computed tomography (CT) scan of the abdomen and pelvis with contrast.

ANSWER AND DISCUSSION

Wandering spleen is the displacement of the spleen from its usual position in the left upper quadrant secondary to elongation of the pedicle. The etiology is usually congenital absence or malformation of gastrosplenic or splenorenal ligaments. In adults, wandering spleen is seen in women of childbearing age secondary to hormonal changes and resulting lax abdominal musculature. Wandering spleen in children is rare and can be associated with torsion or infarct on presentation. This demonstrates the importance of high suspicion as well as the necessity of swift action. More common presentations can include nonspecific lower abdominal pain associated with back pain, nausea, vomiting and flatulence. Diagnosis can be made via ultrasound with Doppler or contrast enhanced CT. Our patient’s CT scan demonstrated ectopic positioning of a normal sized spleen in the left flank, with soft tissue opacity in the left upper abdomen. A central area of increased density within the left upper abdomen was presumably related to rotation of the splenic pedicle. A possible calcified phlebolith within the splenic vein was also noted. We diagnosed the patient with wandering spleen and referred her for surgical evaluation. Splenopexy is ideal if no hemorrhage, phlebolith or other compromise to blood supply is demonstrated. Splenectomy is undertaken if the patient demonstrates infarction, potential for infarction with acute torsion or signs of frank necrosis. Splenectomy was performed secondary to a mass noted intraoperatively. Pathology later revealed benign pancreatic tissue with focal infarct. Our patient has been well to date with no further recurrence of abdominal pain since her procedure. Management of the asplenic patient includes vaccination for pneumococcus, hemophilus influenzae type B (if not already immunized fully), meningococcal group C and yearly influenza vaccine.

Antibiotic prophylaxis is given to asplenic pediatric patients to prevent sepsis and additionally instructed to seek immediate medical attention if fever develops. She was also advised to avoid contact with dogs secondary to increase in risk of canine associated bacteremias causing sepsis in asplenic patients.

Download Tables, Images & References