Ectopic Spleen with Cirrhosis of Liver
Tirthankar Satpathi*, Sarmishtha Mukhopadhyay**
*Post Graduate Trainee; **Consultant Physician, Department of Medicine, B.R. Singh Hospital and Centre for Medical Education and Research, Eastern Railway, Kolkata 700014.
Received : 1.4.2008; Revised : 6.6.2008; Accepted : 26.6.2008
Sir,
Ectopic spleen is a rare anomaly with an incidence of less than 0.2%.1 The etiology may be congenital or acquired. A case of ectopic spleen diagnosed in a patient suffering from cirrhosis of liver with splenomegaly and to portal hypertension is reported.
A 65-year old lady, the mother of six children, presented with gradual development of a lump in lower abdomen predominantly on the left side for 2 years and gradual swelling of whole abdomen for last 8 months. She had moderate pallor with mild pedal edema. Abdominal examination revealed a very firm mass in the left iliac fossa extending towards umbilical and hypogastric areas with a notch on the medial border. Shifting dullness was present.
Investigations showed total RBC- 2.97 X 106/µL, Hb%- 8.8gm%, PCV- 27.7%, MCV- 93.3fl, MCH- 27.6pg, MCHC- 29.6gm/dL, reticulocyte count- 3%, RBC morphology- hypochromic microcytic, total WBC- 1700/µL, polymorph- 71%, lymphocyte- 25%, eosinophil- 4%, ESR- 55mm, platelet count- 90,000/µL, fasting blood sugar- 114 mg%, blood urea- 38 mg%, serum creatinine- 1.1 mg%, serum bilirubin- 0.5mg%, SGPT- 10 IU/L, alkaline phosphatase- 67 IU/L, total protein- 6.1gm%, serum albumin- 2.3gm%, serum globulin- 3.8gm%. Prothrombin time - 15 seconds (control- 11 seconds).
Ultrasonography of abdomen showed 18cm enlarged spleen in left iliac fossa. Portal vein (1.8 cm) and superior vena cava were dilated with moderate ascites. Upper GI endoscopy was normal. CT scan of abdomen showed a mildly shrunken liver without any focal lesion. Portal venous radicals and splenoportal axis were grossly dilated with extensive collateralization. Hepatic veins were normal. The splenic fossa was empty. The enlarged spleen was placed in the pelvis with hilum facing the vertebrae. There was moderate ascites.
Isotopic scan of liver and spleen with 99m Technetium-labeled sulphur colloid also showed grossly enlarged ectopic spleen which appeared to be situated in lower abdomen extending from left to right iliac fossa, hilum facing upwards and towards left, with liver in normal position.
Splenunculi or accessory spleen is a congenital ectopic splenic tissue arising during embryologic period of development.2 Acquired ectopic or wandering spleen is mostly seen in females predominantly in reproductive age group (70-80%) due to hormonally influenced ligamental laxity and splenomegaly.1 Most of the cases are discovered incidentally by abdominal imaging or laparotomy. Usual mode of presentation in symptomatic patients is abdominal pain due to torsion and infarction1 where non-operative treatment has a complication rate of 65%.
Enlarged ectopic spleen due to cirrhosis liver is a very rare entity. A case of recurrent thrombocytopenia associated with symptomatic enlargement of an accessory spleen after splenectomy in cirrhosis3 was reported. Our case is an elderly multipara with cirrhosis of liver and enlarged ectopic spleen. Empty splenic fossa without history of prior splenectomy indirectly indicates that it is probably a case of acquired wandering spleen and not a congenital accessory spleen. Age at diagnosis and mode of presentation are unusual. Because of features of hypersplenism and risk of torsion we referred the patient to surgeon for splenectomy.
Acknowledgement
We are thankful to the P Ghosh and S Das, Department of Radiology, BR Singh Hospital, Kolkata and S Dasgupta, Department of Nuclear Medicine, BR Singh Hospital, Kolkata. We are also thankful to Delta studios, Kolkata for the good quality photographs.
References
- Wg Cdr A Alam, Col MN Sree Ram. Torsion of wandering spleen: Diagnosis using magnetic resonance imaging. MJAFI 2006;62:81-82.
- Harsh Mohan, Amanjit, Bharadwaj S, Handa U. Splenunculi- report of three cases. JAnat Soc India 2002;51:70-71.
- Igor Mishin, Gheorghe Ghidirim. Accessory Splenectomy with Gastroesophageal Devascularization for Recurrent Hypersplenism and Refractory Bleeding Varices in a Patient with Liver Cirrhosis: Report of a Case. Surgery today. 2004;34:12.