reggie-splenic-torsion_at-home-2Case Report: Splenic Torsion

 

Reggie is a six and a half year old Olde English Bulldog

Presentation

Reggie’s family brought him to Caring Hands of Bristow for increased thirst and urination (also called PU/PD), decreased appetite, vomiting, and a painful abdomen. Caring Hands of Bristow performed a thorough work-up on Reggie. Reggie’s veterinarian decided to refer him to the Internal Medicine Division of the Veterinary Referral Center of Northern Virginia (VRC-NOVA). He was evaluated by Dr. Nichole Birnbaum. She found that Reggie had regenerative anemia along with his very painful abdomen.

 

Diagnostics

reggie-splenic-torsion_ultrasound-figure-1

Figure 1

On physical examination, Reggie was bright, alert, and responsive. He had pale mucous membranes and a tense, painful abdomen. Laboratory tests were run on Reggie’s blood and urine at the VRC-NOVA. He was found to have anemia (PCV = 22%) and a urinary tract infection. His chemistry panel was normal.

An abdominal ultrasound showed an enlarged, hypoechoic, pulpy spleen with no viable blood flow and a small amount of free peritoneal fluid. Hyperechoic mesenteric reaction was also noted at the hilus of the spleen. (See the ultrasound image in Figure 1.) All other abdominal organs and structures were within normal limits. A diagnosis of Splenic Torsion was made based on the ultrasound findings.

After consulting with Dr. Bradley, a surgeon at the VRC-NOVA, a recommendation of immediate abdominal exploratory surgery was made. Reggie was transferred to the Surgical Division of the VRC-NOVA.

 

Surgery

A midline abdominal approach to the abdomen was performed and a large, dark, very firm spleen was found (see Figure 2.) This confirmed the Splenic Torsion diagnosis. The stomach was assessed for signs of Gastric Dilatation Volvulus (GDV, also known as “bloat”) but was found to be normal.

 

The spleen was rotated on its vascular pedicle approximately 270 degrees. To prevent reperfusion stress on the system, the spleen was not “derotated”. The twisted vascular pedicle was ligated with a double strand of 0-silk. No additional blood vessels needed ligation. The soft tissue attachments were removed and cauterized using the Ligasure. The spleen was then able to be removed. (see Figure 3.)

A prophylactic right body wall incisional gastropexy was performed to prevent any future GDV. The abdomen was lavaged and a urinary catheter was placed postoperatively. The splenic tissue was submitted for pathology.

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Figure 2

reggie-splenic-torsion_spleen-figure-3

Figure 3

 

Postoperativelyreggie-splenic-torsion_recovering

The preoperative hematocrit of 22% warranted a blood transfusion. Once in recovery the blood transfusion was started to replenish the lost red blood cells, though there was minimal hemorrhage at surgery. Reggie was monitored in the VRC-NOVA’s ICU for blood pressure, EKG changes, and blood oxygen saturation. The recovery was very smooth and uneventful. Reggie was discharged the next evening.

 

Follow Up

Four and half months postoperatively, Reggie is fully recovered and back to normal in all respects.

The differential diagnoses when an enlarged spleen (splenomegaly) is found are:

 

  • Neoplasia
  • Hematoma
  • Abscess
  • Immune Mediated Disease
  • Infectious Disease
  • Abdominal Mass

Surgery is the treatment of choice. It is possible, in acute cases, for the patient to be in shock. Surgery then needs to be performed as soon as possible. In the chronic cases patients still need surgery urgently to avoid:

  • Bloat/GDV
  • Sepsis
  • Peritonitis
  • Splenic Necrosis
  • DIC

Splenic torsion is most often associated with gastric–dilatation volvulus (GDV) complex and tends to follow the pyloric antrum as it turns. Splenic torsion not associated with GDV, as seen in this case, almost always creates more extreme vascular compromise and reguires splenectomy.

reggie-splenic-torsion_at-home

The cause of independent splenic torsion is unknown. It is most common in the deep-chested breed dogs (that are also prone to GDV) including German Shepherd Dogs, Great Danes, and English Bulldogs. These breeds accounted for 50% of splenic torsion cases in one study.

Risk factors associated with death included septic peritonitis, intraoperative hemorrhage, and respiratory distress. Splenic cancer is very uncommon.

Breakdown of the two supportive ligaments, gastrosplenic and splenocolic ligaments, is thought to occur due to trauma or intermittent partial gastric rotation. Accurate diagnosis and elimination of other causes of splenic thrombosis (cardiovascular, liver, renal, neoplasia, hyperadrenocorticism or Cushing’s) is imperative. As in this case, accurate prompt diagnosis and treatment led to a successful full recovery.

 

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