wandering spleen ( ws ) is a rare condition in which the spleen is located anywhere in the abdomen other than in its usual place ; however , other terms are used to describe this clinical entity , including  displaced spleen  ,  drifting spleen  ,  floating spleen  ,  pelvic spleen  ,  splenic ptosis  ,  splenoptosis  , 
although it remains enigmatic , the abnormal location of the spleen may be attributed to malformation or total agenesis of the splenic suspensory ligaments because of abnormal development of the dorsal mesogastrium .
therefore , the spleen may either drop into the abdominal cavity and be suspended only by extremely flexible ligaments , or float in the abdominal cavity suspended only by its pedicle .
in addition , wandering spleen may occasionallyoccur as a result of weakening of the suspensory splenic ligaments by clinical processes such as trauma , pregnancy , and connective tissue diseases .
splenic torsion , the major complication of ws , was first mentioned in the german literature in 1885 . since then
, ws and its clinical aspects have been fully identified , and ws has gradually become a well - known clinical entity.1,2 in this article we report two cases of ws , one of whom presented with torsion .
a 21-year - old female was admitted to our emergency department with an acute abdomen . apart from abdominal pain continuing for 36 hours , her medical history was insignificant .
physical examination revealed a giant mass located in the left abdominal quadrant , and generalized abdominal tenderness .
routine biochemical parameters were normal except for a moderate leukocytosis ( 16,500/mm ) and high c - reactive protein ( crp ) ( 80 mg / l ) .
combined abdominal sonography and contrast - enhanced abdominopelvic computed tomography ( ct ) demonstrated the absence of a spleen in its normal position , with a 15  7 cm solid mass extending from the stomach to the pelvis in the left abdomen that was consistent with ws , and no contrast enhancement within the splenic parenchyma ( figure 1 ) .
an urgent laparotomy revealed a significantly enlarged , infarcted ws secondary to splenic torsion of 540 ( figures 2 and 3 ) .
the patient was discharged on the fourth postoperative day , to come back for vaccination two weeks later .
a 19-year - old female was seen in our outpatient clinic with enuresis and vague lower abdominal pain of six months duration . she had been treated for urinary tract infection several times within the previous three months .
an enlarged ws of 16  6 cm in size extending from the left costal margin to the pelvis was demonstrated on abdominal sonography .
contrast - enhanced abdominopelvic ct scan revealed an enlarged ws extending from the greater curvature to the urinary bladder , and a 3  2 cm mass consistent with an accessory spleen ( figure 3 ) . because the spleen was enlarged , without any vascular compression , other causes of splenomegaly were investigated .
surgical treatment was considered for management after hematological consultation . during exploratory laparoscopy , an enlarged ws with an accessory spleen at its hilum
there were dense adhesions between the ws and the urinary bladder . given that the accessory spleen was evaluated to be adequate for further splenic function and the spleen was too enlarged to be replaced in its original position , laparoscopic splenectomy was preferred .
ws is a rarely seen birth defect with an incidence of < 0.2% , caused by an unusually long vascular pedicle which allows migration of the spleen from its normal anatomic position , and is most commonly diagnosed in young children as well as in women between the ages of 20 and 40 years . the first clinical description of ws , confirmed by autopsy , was by johannes van horne , a dutch physician , in 1667.24 the clinical presentation of ws may be variable , from an asymptomatic patient to one with mild abdominal pain , signs of acute abdomen , or acute pancreatitis .
the most common symptom of ws is abdominal pain caused by either splenic complications or mass effect .
splenic torsion , the most important complication of ws , may be either acute - complete or intermittent - incomplete .
acute - complete splenic torsion contributes to splenic ischemia in which the patient presents with acute abdominal symptoms , as did our first case .
however , intermittent - incomplete splenic torsion may lead to venous congestion and subsequent hypersplenism .
therefore , such patients may present with intermittent or sustained vague abdominal pain , and may be found to have biochemical abnormalities because of hypersplenism,5,6 as did our second case .
patients with ws may also present with complications associated with other intra - abdominal organs , such as gastrointestinal obstruction secondary to splenic adhesions or a long splenic pedicle , pancreatic necrosis secondary to compression of the pancreatic tail , pancreatitis secondary to displacement of the pancreatic tail into the splenic hilum , bleeding from gastric varices secondary to splenic venous hypertension , and urinary symptoms secondary to compression of the ureters or the urinary bladder . of note , ws may be asymptomatic with or without a palpable intra - abdominal mass , and is diagnosed incidentally.710 the absence of spleen in its normal anatomic position and a presence of an intra - abdominal mass that has similar characteristics with the spleen are major determinants of diagnosis of ws by any imaging modalities utilized .
abdominal sonography and doppler scan may not only demonstrate a ws but can also evaluate splenic blood flow to rule out a possible splenic torsion.11,12 contrast - enhanced abdominopelvic ct scan also provides information about the exact location of ws in relation to other intra - abdominal organs , and the viability of the spleen in the setting of a possible splenic torsion.13 other diagnostic imaging modalities include radionuclide scan and mri.14 combined utilization of abdominal sonography and ct provided a correct diagnosis of ws in our both cases .
symptomatic patients with ws warrant surgical treatment , but the management of asymptomatic ws remains controversial
. however , many authors found a high rate of complications , splenic torsion in particular , associated with conservative treatment.15 since elective surgical treatment have the advantage of preservation of a viable spleen , surgical treatment seems to be the best option in asymptomatic ws .
currently , there are two surgical treatment options for ws , ie , splenopexy and splenectomy.1619 each procedure can be carried out by open or minimally invasive surgery .
many authors recommend splenopexy in uncomplicated cases , especially in children ; however , in cases of infarction due to splenic torsion , splenectomy seems to be the treatment of choice whether laparoscopic or open , depending on the patient s situation , size of the spleen , and experience of the surgeon . in conclusion , wandering spleen should be borne in mind for patients presenting with a palpable intra - abdominal mass causing acute or intermittent abdominal symptoms .
 wandering spleen is a rare clinical condition which presents with a variety of symptoms with abdominal pain , abdominal mass , and acute abdomen . 
 it may also remain silent until diagnosed by a routine imaging study . 
 treatment options may differ depending on the presenting clinical picture . 
 herein we present two cases of wandering spleen treated by splenectomy , with one of them admitted to our emergency clinic with torsion . 
Introduction
Case report 1
Case report 2
Discussion