A painful reminder

Images in Gynecology

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A painful reminder The patient had sharp abdominal pain and a complicated medical history Neeraj Desai, MD; Anna K. Parsons, MD; Shelly W. Holmström, MD

Case notes A 31-year-old nulligravida presented with a 5-day history of new, constant, stabbing pain in the suprapubic region and right lower quadrant of the abdomen. It was not associated with activity, menses, gastrointestinal symptoms, or bladder symptoms. Her history was significant for polycystic ovarian syndrome, anemia, endometriosis, and a splenectomy at age 17 years for rupture after a motor vehicle accident. Abdominal examination revealed voluntary guarding but no rebound tenderness or palpable masses. Pelvic examination disclosed a 2-cm, firm, nodular mass in the right posterior cul-de-sac. Palpable on rectovaginal examination, it was tender to the touch. A serum ␤-human chorionic gonadotropin test revealed negative findings. Ultrasound confirmed a fixed, 4- ⫻ 2-cm, solid, homogeneous, bilobed mass with hilar blood flow in her right posterior cul-de-sac (Figures 1 and 2). Palpation with a probe reproduced her pain. The patient underwent operative laparoscopy. A gnarled, 3⫻ 2-cm, reddish-purple implant was found on her right uterosacral ligament (Figures 3-5). After excision of the mass, her pain resolved. Conclusions Histology confirmed splenosis, which is the autotransplantation of splenic tissue following trauma; spleen fragments often drift down to the deep pelvis. In 1939, Buchbinder and Lipkoff1 first described the condition in a young woman who underwent surgery for diffuse peritoneal endometriomas. Rare symptoms include focal pain and intraperitoneal bleeding after traumatic rupture of parasitized vessels. A liver/spleen scan with technetium-99m-labeled microspheres that are sequestered by the ectopic reticuloendothelium can provide an accurate preoperative diagnosis.2 Splenosis should be considered in anyone with a remote history of splenic rupture and a fixed, small, firm, abdominal or pelvic mass. The differential diagnosis includes metastatic cancer, hemangiomas, accessory spleen, and endometriosis, with which it has been confused in previous case

FIGURE 1

Ultrasound identified 3.76-cm, solid, homogenous, bilobed mass in patient’s right posterior cul-de-sac. Desai. A painful reminder. Am J Obstet Gynecol 2010.

reports.2-4 Resection of asymptomatic splenosis is discouraged, because the residual spleen tissue is thought to scavenge blood-borne bacteria and debris. However, if pain symptoms can be recreated on ultrasound-focused palpation of the lesions, laparoscopic excision is likely to be curative.2 f

FIGURE 2

From the Department of Obstetrics and Gynecology, University of South Florida, Tampa, FL. Received April 30, 2009; revised June 2, 2009; accepted Aug. 17, 2009. Cite this article as: Desai N, Parsons AK, Holmström SW. A painful reminder: the patient had sharp abdominal pain and a complicated medical history. Am J Obstet Gynecol 2010;202:405.e1-2. 0002-9378/$36.00 © 2010 Published by Mosby, Inc. doi: 10.1016/j.ajog.2009.08.017

Hilar blood flow within mass was seen on ultrasound. Desai. A painful reminder. Am J Obstet Gynecol 2010.

APRIL 2010 American Journal of Obstetrics & Gynecology

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Images in Gynecology FIGURE 3

Laparoscopy revealed 3- ⫻ 2-cm, gnarled, reddish-purple implant on patient’s right uterosacral ligament. Desai. A painful reminder. Am J Obstet Gynecol 2010.

FIGURE 4

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FIGURE 5

Attachment to posterior peritoneum was evident during laparoscopy. Desai. A painful reminder. Am J Obstet Gynecol 2010.

REFERENCES 1. Buchbinder JH, Lipkoff CJ. Splenosis: multiple peritoneal splenic implants following abdominal injury. Surgery 1939;6:927-34. 2. Tasci Y, Kayikcioglu F, Cavusoglu D, Gokcin H. Splenosis mimicking pelvic mass. Obstet Gynecol 2005;106:1167-9. 3. Watson WJ, Sundwall DA, Benson WL. Splenosis mimicking endometriosis. Obstet Gynecol 1982;59(Suppl):51-3S. 4. Matonis LM, Luciano AA. A case of splenosis masquerading as endometriosis. Am J Obstet Gynecol 1995;173:971-3.

Mass was palpated with laparoscopic grasper instrument. Desai. A painful reminder. Am J Obstet Gynecol 2010.

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American Journal of Obstetrics & Gynecology APRIL 2010