Home // About Us // Privacy Statement // Sponsorship Policy // Contact Us

Case Report #1

Images of intraabdominal splenosis
David Dewar, Costa Karhiloo, John Gani
Department of Surgery, John Hunter Hospital, Lookout Road, Lambton, NSW, Australia, 2305




In July 2005 a 50 year-old man was referred to the surgical outpatients clinic for the further investigation of right upper quadrant pain, abnormal liver function tests (GGT 251, AST 58, ALT 95), and an abnormal CT scan. This showed multiple low-attenuation lesions in the liver and throughout the peritoneal compartment.

(Fig 1)



He denied any constitutional symptoms (weight loss, fever, malaise), and was on no regular medications. He drank five units of alcohol per week. His background history included hepatitis C for five years, and a traumatic laparotomy with splenectomy following a motor vehicle accident twenty-five years ago.

He underwent a diagnostic laparoscopy. At operation he was found to have multiple splenunculi.

(Fig 2)



confirmed by histology.

(Fig 3).



A liver biopsy showed macronodular cirrhosis and moderate inflammation. There was no evidence of malignancy. With malignancy ruled out his liver abnormalities were attributed to ongoing cirrhosis, and he was referred to the hepatology clinic for ongoing management.

Splenosis refers to the heterotopic autotransplantation of splenic tissue often following traumatic injury or splenectomy, with splenunculi referring to the individual splenic deposits. Splenunculi are generally asymptomatic, often multiple, and are usually found in the abdomen. There are also reports of splenunculi found in the pleural and pericardial spaces following diaphragmatic rupture, and case reports of subcutaneous depositions (1,2). Splenunculi differ from congenital accessory spleens as they have no central vascular hilum, and fewer germinal centres. Splenunculi are cytologically identical to normal splenic tissue. The functional role of splenosis is unclear and probably related to the extent of splenic tissue (3). Splenunculi can remove abnormal red blood cells and platelets. This may be useful post traumatic splenectomy, or deleterious when splenectomy is done electively, for idiopathic autoimmune thrombocytopenia (4, 3). Small splenunculi may be non functional with ongoing circulation of Howell-Jolly bodies, suggesting that function is dependant on the amount of splenic tissue (5). Although splenosis has been shown to be protective for encapsulated bacteria in animal models, there is limited evidence for this in humans (6,7). Therefore splenectomized patients with splenosis should be vaccinated against encapsulated bacteria.

In a patient with few risk factors for malignancy a diagnosis of splenosis can be made using selective spleen scintigraphy with Tc-99m-labelled heat-denatured autologous red blood cells (8,9). The value in this approach is that the patient avoids surgery. However such nuclear medicine investigations do not rule out malignancy, and in the context of a patient with a high pre test probability the diagnostic method of choice is a laparoscopic tissue biopsy. Splenosis as a cause of intraperitoneal nodules on imaging needs to be considered in all patients who have had a splenic rupture.




References

1) Hibbeln JF, Wilbur AC, Schreiner VC, Trepashko DW: Subcutaneous splenosis. Clinical Nuclear Medicine 20: 591, 1995
2) Khosravi MR, Margulies DR, Alsabeh R, Nissen N, Phillips EH, Morgenstern L SO: Consider the diagnosis of splenosis for soft tissue masses long after any splenic injury. Am Surg 70(11):967-70, 2004
3) Pearson HA, Johnston D, Smith KA, Touloukian RJ: The born again spleen- Return of splenic function after splenectomy for trauma. New England Journal of Medicine 298(25): 1389-1392, 1978
4) Macfarlane D, Shulkin B: Splenosis in a patient with autoimmune thrombocytopenia. Clinical Nuclear Medicine 21(1): 61-62, 1996
5) Spencer R P, Pannullo A M, Karimeddini M: "Ineffective" Splenosis Detected on Tc-99m Labeled White Cell Imaging. Clinical Nuclear Medicine 22(4):271-272, 1997
6) Dickerman JD, Horner SR, Coli JA, Gump DW: The protective effct of intraperitoneal splenic autotransplants in mice exposed to an aerosolised suspension of type III Streptococcus Pneumoniae. Blood 54: 354-8, 1979
7) Acs G, Furka I, Miko I, Szendroi T, Hajdu Z, Sipka S, Barath S, Aleksza M, Cispo I, Balo E, Balint A, Fekete K: Comparative hematologic and immunologic studies of patients with splenectomy and spleen autotransplantation. Magyar Sebeszet 58(2):74-9, 2005
8) Bachofner A, Poeppel T D, Scherer A: A tumour masquerade. Lancet 366:606, 2005
9) Ehy L, Kkp L: Intra-abdominal splenosis: How clinical history and imaging features averted an invasive procedure for tissue diagnosis. Australasian Radiology 49:4 342, 2005





Figure Legends

Figure 1: Axial CT scans: a) Splenunculi adherent to the anterior abdominal wall. b) Splenunculi in the left iliac fossa. c & d) Multiple non-enhancing low attenuation lesions throughout the liver.





Figure 2: Intraoperative images of splenunculi; a) Splenunculi in the left iliac fossa. b) Splenunculi adherent to the anterior abdominal wall.





Figure 3: a) Microscopic appearance of one of the splenunculi, showing red pulp and splenic nodules. b) Microscopic appearance of the liver showing macro nodular cirrhosis, collagen and fibrosis stain red, and the remaining nodules of hepatocytes stain yellow.








Images of intraabdominal splenosis

David Dewar, Costa Karhiloo, John Gani
Department of Surgery, John Hunter Hospital, Lookout Road, Lambton, NSW, Australia, 2305
David Dewar: c/o Department of Surgery, John Hunter Hospital, Lookout Road, Lambton, NSW, Australia, 2305. Ph 49213000, ddewar@med.usyd.edu.au
Sources of financial support: Nil
Case Report
Splenosis, Splenunculi



Images of intraabdominal splenosis David Dewar, Costa Karhiloo, John Gani