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LETTER TO EDITOR Table of Contents  
Ahead of print publication
Accessory spleen torsion simulating acute appendicitis


 Department of General Surgery, Celia Sánchez Manduley Hospital, Manzanillo, Granma, Cuba

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Date of Submission24-Feb-2022
Date of Decision25-Feb-2022
Date of Acceptance26-Feb-2022
Date of Web Publication18-Oct-2022
 


How to cite this URL:
Montero Verdecia Y, Fonseca Sosa FK, Pompa YS, León Fonseca ML. Accessory spleen torsion simulating acute appendicitis. Indian J Med Spec [Epub ahead of print] [cited 2022 Dec 5]. Available from: http://www.ijms.in/preprintarticle.asp?id=358773




Dear Editor,

Accessory spleen (AS) is defined as ectopic splenic tissue that develops due to the failure of cell fusion during embryonic development while migrating from the midline to the left upper quadrant. AS includes isolated spleen tissue outside the normal spleen.[1] AS torsion is a very rare condition often difficult to diagnose and is commonly an unexpected finding when operating on patients with acute abdominal findings.[2]

We present the case of a 21-year-old male who came to the emergency department for abdominal pain that began 1 day ago in the mesogastrium and then moved to the lower right quadrant, which intensified progressively, was constant, without radiation, did not relieve with pain relievers, it was accompanied by anorexia and nausea and increased with the realization of sudden movements.

On physical examination, the patient had tachycardia of 102 beats/min and a fever of 38.5°C. Examination of the abdomen revealed pain on superficial and deep palpation in the lower right quadrant, with muscular defense and peritoneal reaction. Laboratory tests showed leukocytosis (12 × 109/l), with neutrophilia (85%), and the rest of the tests were normal. In imaging techniques, abdominal ultrasound (US) did not help make the diagnosis.

Emergency intervention was performed by McBurney incision, identifying a normal cecal appendix. At 60 cm from the ileocecal valve next to the mesenteric border of the jejunal loop, it was identified an ischemic AS of approximately 4 cm with torsion of the vascular pedicle [Figure 1]. AS was resected without difficulty. Histology examination of the resected specimens revealed splenic tissue with areas of infarction. The patient evolved satisfactorily and was discharged on the 3rd postoperative day.
Figure 1: Intraoperative picture showing ischemic accessory spleen next to the mesenteric border of the jejunal loop

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AS is asymptomatic and rarely causes clinical symptoms. However, in some cases, may present with symptoms related to torsion and infarction. Affected patients range from infants to the elderly, with more than half of the reported cases in children.[2]

The presence of more than one spleen may be found in the supracolic compartment along the splenic artery, in the greater gastric curvature, or around the suspensory ligaments of the spleen, but small ASs (splenunculus) may be found in the greater and lesser omentum, in the mesenteries and next to the genital organs.[3]

Computed tomography (CT) scan and magnetic resonance imaging play an important role in the diagnosis of AS. US examination gives the possibility to suspect a pathology of the AS. However, in some cases, the US evaluation of increased echogenicity of fatty mesenteric tissue may be difficult to appreciate, whereas the increased density of mesenteric fat can be quite easily and definitely demonstrated by CT scan.[4]

Reported complications of an AS are torsion around the vascular pedicle or hemorrhage due to rupture. Other complications such as intestinal obstruction, infection, and peritonitis have been less commonly reported. However, complications such as torsion or hemorrhage of ASs usually present as a surgical emergency and need surgery on an urgent basis. Resection of the AS should be performed by conventional or video laparoscopic surgery.[5]

Declaration of patient consent

The authors certify that they have obtained all appropriate patient consent forms. In the form the patient(s) has/have given his/her/their consent for his/her/their images and other clinical information to be reported in the journal. The patients understand that their names and initials will not be published and due efforts will be made to conceal their identity, but anonymity cannot be guaranteed.

Financial support and sponsorship

None.

Conflicts of interest

There are no conflicts of interest.



 
  References Top

1.
Palumbo V, Mannino M, Teodoro M, Menconi G, Schembari E, Corsale G, et al. An extremely rare case of an oversized accessory spleen: Case report and review of the literature. BMC Surg 2019;19:45-51.  Back to cited text no. 1
    
2.
Yoshida M, Saida T, Masuoka S, Urushibara A, Chiba F, Masumoto K. Preoperative diagnosis of a torsioned accessory spleen. J Med Ultrasound 2021;29:116-8.  Back to cited text no. 2
  [Full text]  
3.
Sisto Díaz A, Sierra Enrique EN. Surgical affections of the spleen. In: Soler Vaillant R, Mederos Curbelo ON, editors. Surgery. Habana: Ecimed; 2018. p. 165.  Back to cited text no. 3
    
4.
Trinci M, Ianniello S, Galluzzo M, Giangregorio C, Palliola R, Briganti V, et al. A rare case of accessory spleen torsion in a child diagnosed by ultrasound (US) and contrast-enhanced ultrasound (CEUS). J Ultrasound 2019;22:99-102.  Back to cited text no. 4
    
5.
Sheth H, Chaudhari S, Sinha Y, Prajapati R. Infarcted accessory spleen masquerading as a mesenteric cyst. BMJ Case Rep 2018;2018:92-8.  Back to cited text no. 5
    

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Correspondence Address:
Fernando Karel Fonseca Sosa,
Esperanza Street #73 between Guadalupe and San Javier, Manzanillo, Granma 87510
Cuba
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Source of Support: None, Conflict of Interest: None

DOI: 10.4103/injms.injms_24_22



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