"A rare anatomical anomaly, the wandering spleen, can present as a silent threat, its unusual mobility leading to severe, recurrent abdominal pain by mechanically triggering pancreatitis."
This case highlights a peculiar and often overlooked cause of severe abdominal discomfort: a wandering spleen. This condition, where the spleen is not anchored in its usual position, can lead to a cascade of medical issues, most notably recurrent pancreatitis, by twisting and pulling on nearby organs. The intricate interplay between the spleen and the pancreas, particularly the pancreatic tail, underscores the importance of considering less common diagnoses when faced with persistent and severe abdominal pain.
A 45-year-old woman presented to the emergency room with excruciating left upper abdominal pain that radiated to her back, accompanied by an alarmingly high lipase level of 900 units per liter – more than five times the upper limit of normal. This severe episode was not an isolated incident; she had experienced milder versions of similar attacks since adolescence. Years prior, she had been informed her spleen was hypermobile and positioned lower than expected, yet this critical piece of information was never linked to her recurring pain. This oversight is illustrative of how seemingly minor anatomical variations can have significant, albeit delayed, clinical consequences.
The true extent of her condition became apparent only when surgeons finally intervened. Rather than residing in the left upper abdomen, her spleen was found in her pelvis, tethered by stretched peritoneal tissue that also encased her pancreatic tail. This detailed case, documented in the journal Clinical Case Reports by a multidisciplinary team from the University of Nebraska Medical Center, sheds light on a mechanical etiology for recurrent pancreatitis that often escapes routine diagnostic considerations. The investigation revealed a spleen measuring an impressive 17.7 to 18.3 centimeters, a significant enlargement, which had undergone repeated torsional events.
The underlying cause of this spleen’s errant journey is a developmental anomaly known as wandering spleen. In this condition, the ligaments that normally secure the spleen to its anatomical position in the left upper quadrant are underdeveloped or unusually lax. Globally, the incidence of wandering spleen is remarkably low, estimated at less than 0.2%. It predominantly affects two demographic groups: children under the age of 10 and women of reproductive age, particularly those who have experienced multiple pregnancies. The patient in question was multiparous, and hormonal influences on ligamentous laxity are a proposed factor contributing to this observed pattern.
The consequence of these lax attachments is that the spleen dangles precariously from a long, tortuous vascular stalk. This stalk is susceptible to rotation, a phenomenon documented in medical literature with twists ranging from a mild 90 degrees to a severe over 2,000 degrees. In this patient’s case, diagnostic imaging captured the dynamic nature of the condition. An initial CT scan revealed splenomegaly (an enlarged spleen), an abnormally positioned spleen, and clear signs of acute pancreatitis. Specifically, the pancreatic tail was observed to be swirled around the splenic hilum, exhibiting poor enhancement indicative of compromised blood flow. Remarkably, a follow-up scan conducted two days later showed a partial untwisting of the spleen, with improved blood supply and a shift in its position towards the pelvis.
A subsequent CT angiogram confirmed the spleen’s substantial size at 17.7 centimeters and highlighted the rotation of its hilum and torsion of the splenic artery. Crucially, blood flow through the splenic and portal veins remained preserved. By the time surgical intervention was decided upon, the spleen had enlarged further to 18.3 centimeters, and her platelet count had decreased to 134,000 per microliter, a finding that can be associated with splenic enlargement due to increased sequestration.
The precise mechanism by which the wandering spleen precipitated pancreatitis was determined to be mechanical rather than metabolic. The pancreatic tail lies in close proximity to the splenic hilum and is anatomically connected via the splenorenal ligament. When the spleen rotated, it exerted traction and caused kinking of the pancreatic tail. This mechanical stress was sufficient to inflame the pancreas, leading to elevated lipase levels. The subsequent partial untwisting of the spleen would have relieved this pressure, allowing lipase levels to decrease.
Further diagnostic workup ruled out other common causes of pancreatitis. Liver enzymes and general blood counts were within normal limits. An upper endoscopy revealed a normal gastric and duodenal lining, and biopsies were negative for Helicobacter pylori infection, a common culprit for gastrointestinal issues. Intriguingly, imaging from several years prior had already documented a pelvic spleen measuring 17.3 centimeters with an intact vascular stalk, providing retrospective evidence of long-standing splenic ectopia, or displacement.
This patient’s case is not an isolated incident. The medical literature contains several similar reports, underscoring the need for greater awareness of wandering spleen as a cause of recurrent acute pancreatitis. In 2018, a case report in Case Reports in Gastrointestinal Medicine advocated for recognizing wandering spleen as a cause of recurrent pancreatitis, describing a 28-year-old woman who underwent splenopexy, a procedure to anchor the spleen. A subsequent case in Annals of Medicine and Surgery in 2019 detailed torsion involving the pancreatic tail in an 18-year-old experiencing recurrent left upper quadrant pain. Similarly, a 2008 report in JSLS documented the same clinical presentation in a 20-year-old woman.
The urgency associated with wandering spleen-related complications is often high, with many cases necessitating emergency surgery. A review of published cases, compiled by the authors of the current report, encompassing 20 individuals aged 3 to 98, revealed that 17 involved the pancreatic tail and that the spleen was infarcted (had its blood supply cut off) in half of these instances. Nineteen patients required surgical intervention, and a significant 11 of these operations, nearly 58%, were performed as emergencies. More recent data, from five cases identified since 2023, shows that four necessitated emergency open splenectomy due to torsion with infarction.
The degree of splenic torsion appears to be a critical factor in determining the severity of the outcome. Partial torsion, less than 360 degrees, was generally associated with mild, reversible pancreatitis and a viable spleen. In contrast, severe torsion, in the range of 720 to 1,080 degrees, almost invariably led to infarction and the forced removal of the organ. Pancreatitis in these severe cases was typically mild and resolved once the splenic torsion was corrected. A key diagnostic clue on imaging is the "whirl sign," a swirling pattern of vessels that was diagnostic in over 90% of these identified cases.
In this patient’s specific situation, the preservation of blood flow to the spleen allowed for a scheduled surgical procedure rather than an emergency operation. This elective approach was significant, as the surgery itself presented unique challenges. Surgeons were unable to locate the spleen in its expected anatomical position and had to undertake a systematic laparoscopic exploration. This involved retracting the splenic flexure of the colon to expose the kidney capsule before finally identifying the organ deep within the pelvic cavity. The spleen and pancreas were then carefully repositioned back to the left upper quadrant. Following the removal of the spleen, the pancreatic tail was found to be so mobile that it required an additional procedure, a pancreatopexy, to secure it in place by stitching it to the surrounding tissues.
The patient’s recovery was remarkably swift. She was discharged on the first day after surgery, experiencing only mild soreness and fatigue, which resolved independently. She returned to work within five days and was symptom-free at her one-month follow-up appointment. A subsequent CT scan two months post-operation confirmed that both the spleen and pancreas had returned to their normal anatomical positions, further illustrating the intermittent nature of her underlying condition.
It is crucial to contextualize this case. As a single patient report, it does not suggest that unexplained abdominal pain is typically caused by a displaced organ. Gallstones and alcohol consumption remain the predominant causes of pancreatitis. The authors’ primary objective is to highlight a specific, albeit rare, diagnostic pathway: when imaging reveals an organ in an abnormal position in conjunction with recurrent pain, the organ’s displacement itself may be the diagnosis. Furthermore, treatment is not uniformly organ removal. Evidence from multicenter pediatric data and several adult case reports supports splenopexy – surgically anchoring the spleen in its correct position – as a viable and often preferred option when the spleen is viable and the patient is hemodynamically stable. In this particular case, however, the decision was made to remove the spleen due to unexplained splenomegaly, a falling platelet count, and the repeated history of torsional events.
The practical takeaway for both clinicians and patients is clear. Individuals experiencing recurrent, unexplained abdominal pain should diligently discuss these symptoms with their healthcare providers, rather than assuming a rare anatomical cause. Similarly, sudden, severe abdominal pain always warrants immediate and thorough medical assessment to rule out life-threatening conditions. This case serves as a potent reminder that the human body can harbor anatomical curiosities that, while rare, can have profound and painful consequences.
