International Journal of Surgery Open 6 (2017) 19e21

Contents lists available at ScienceDirect

International Journal of Surgery Open

journal homepage: www.elsevier.com/locate/ijso

Case Report

Surgical treatment of liver cirrhosis and hypersplenism with huge accessory

spleen e A case report
Bo Zhuang*, Shian Yu, Ruyan Jin, Daojun Gong
Department of General Surgery, The Jinhua Hospital of Zhejiang University, Jinhua, Zhejiang, China

a r t i c l e i n f o a b s t r a c t

Article history: Introduction: Accessory spleens which are common and separate from the main body of the spleen, are
Received 5 February 2017 the healthy splenic tissues and usually smaller than 2cm. Here, we report a case of liver cirrhosis and
Received in revised form hypersplenism with a huge accessory spleen. This case report and literature review describes the
16 February 2017
management of the enlarged accessory spleen.
Accepted 16 February 2017
Available online 20 February 2017
Presentation of case: We report the case of a 47-year-old man who presented with discomfort in the left
upper abdomen and hypodynamia for more than 3 months. The color Doppler sonography and
abdominal contrast-enhanced computed tomography (CT) revealed a well-marginated ovoid mass,
Keywords:
Case report
approximately 13.0 cm  8.0 cm  5.0cm between stomach and spleen. The patient underwent the
Accessory spleen laparoscopic splenectomy because of liver cirrhosis and hypersplenism. The result that the mass is the
Hypersplenism enlarged accessory spleen was confirmed by pathological diagnosis. Clinical symptoms were relieved in 1
Liver cirrhosis month after operation.
Discussion: Accessory spleens could enlarge to more than 10cm in patients with liver cirrhosis. CT and
laparoscope can be used for preoperative, intraoperative diagnosis of accessory spleens. Laparoscopic
splenectomy associated huge accessory splenectomy is one of the effective treatments of patients with
liver cirrhosis and hypersplenism.
Conclusion: Because such a large accessory spleen is rare, to a certain extent, it renders diagnosis more
difficult. If we are familiar with its character, unnecessary treatment can be avoided.
© 2017 The Authors. Published by Elsevier Ltd on behalf of Surgical Associates Ltd. This is an open access
article under the CC BY-NC-ND license (http://creativecommons.org/licenses/by-nc-nd/4.0/).

1. Introduction unnecessary laparotomy.

Accessory spleens are relatively common and usually smaller
than 2cm [1,2], which are always located at the splenic hilum or
adjacent to the pancreatic tail in the most cases [1,3]. Typically,
accessory spleen appears as a well-marginated round solitary
nodule and enhances homogeneously on the contrast-enhanced
image [1,2]. Splenomegaly with hypersplenism is one of the clin-
ical manifestations of liver cirrhosis. Laparoscopic splenectomy
including accessory spleen is regarded as an effective treatment, or
the residual accessory spleen may enlarge and hypersplenism
would reappear after splenectomy [4]. Computed tomography and
laparoscopy could be the effective methods to confirm the diag-
nosis of accessory spleen. Therefore, this is a problem which de-
serves to be discussed, how to evaluate and treat the left upper
abdominal mass in patients with cirrhosis hypersplenism to avoid
* Corresponding author.
E-mail address: broal213@sina.com (B. Zhuang).
Here, we report a case of liver cirrhosis and hypersplenism with
huge accessory spleen more than 10cm located at the left upper
abdomen. The case report is compliant with the SCARE Guidelines
[5].
2. Case presentation
A 47-year-old Chinese male driver referred by digestive physi-
cian complained discomfort in the left upper abdomen and hypo-
dynamia for more than 3 months. There was an immovable masse
(about 5  5cm) detected in the left upper abdomen and no other
associated symptoms. He suffered from Hepatitis B-related liver
cirrhosis and had no history of alcohol, jaundice, abdominal
trauma, weight loss and the past medical history was unremark-
able. On admission, chest, cardiovascular, central nervous, and the
musculoskeletal systems were normal on examination.
Laboratory data including tumor markers and liver function test
results were almost normal except a platelet count of 22  10^9/L, a

http://dx.doi.org/10.1016/j.ijso.2017.02.002
2405-8572/© 2017 The Authors. Published by Elsevier Ltd on behalf of Surgical Associates Ltd. This is an open access article under the CC BY-NC-ND license (http://
creativecommons.org/licenses/by-nc-nd/4.0/).
20 B. Zhuang et al. / International Journal of Surgery Open 6 (2017) 19e21

white blood cell count (WBC) of 2.6  10^9/L. Severe gastro-

esophageal varices were confirmed in gastroscopy and upper
gastrointestinal radiography. The CT scan showed the mass had a
trophic vessel linking to the splenic artery (Fig. 1). The pancreatic
and splenic tissue were normal in appearance on both CT and ul-
trasound images. Bone Marrow Examination revealed hyper-
splenism: increased megakaryocytic cells with poor function. The
size of the mass, which had been rarely reported for an accessory
spleen, made an exact diagnosis uncertain. In additional, stromal
tumor and gastrointestinal tumor should be also considered.
After psychological care and good preparation of gastrointes-
tinal tract, the patient underwent the operation of laparoscopic
splenectomy due to hypersplenism. We found that there was
micronodular cirrhosis without ascites, perigastric varices. The
spleen was normal (11.0 cm  8.0 cm  6.0cm) and a mass with
13.0 cm  8.0 cm  5.0cm between stomach and pancreas, which
was suggestive of an accessory spleen (Figs. 2 and 3). The first stage,
we exposed the splenic pedicle 2 and cut by the Endo-Cutter; the
second stage, the same method was used to deal with the splenic Fig. 2.
pedicle 1. Then the spleens were put into the specimen bag and
taken out from umbilical incision. Blood loss was less 100ml and
operative time was about 2 hours during the operation. Cefazolin
was used in half an hour before operation and stopped within 24
hours after operation. Pathologic examination of the resected
specimen revealed splenic tissue. The patient was discharged from
the hospital one week later and the index of WBC, Hb, PLT returned
to normal after one month. Six months later, routine laboratory
investigation: WBC, coagulation profile, liver function test revealed
no abnormalities and there was no symptom recurrence.

3. Discussion

Accessory spleens are common and affect between 10% and 30%
of the population [6]. It can be found anywhere almost in the
abdominal cavity, and they will enlarge after splenectomy. On the
other hand, splenomegaly and hypersplenism are the typical
symptoms of liver cirrhosis. In this case, accessory spleens could
also enlarge, even more than 10cm, in patients with liver cirrhosis.
In our case, the patient received laparoscopic splenectomy
because of hypersplenism, and we found that the accessory spleen
is exceptionally large (>10cm), which was larger than normal
spleen. It has been reported that accessory spleens had compen-
satory hypertrophy as a result of previous splenectomy, which
sometimes reached 3e5cm in size [7]. The accessory spleen was
huge despite no history of splenectomy. To our knowledge, this is
one of the largest accessory spleens in the English medical
Fig. 1.
Fig. 3.
literature. The findings of previous studies support the hypothesis
that the main mechanisms of accessory spleen enlargement in
patients with portal hypertension are: (1) hemodynamic conges-
tion secondary to intrahepatic or extrahepatic obstruction of the
portal vein, or both; (2) reticuloendothelial hypertrophy; (3)
compensating hypertrophy [4]. Although it is difficult to define the
exact mechanisms, the first one may be the most important
because of liver Cirrhosis caused by Hepatitis B virus.
Furthermore, the measures of recognition and appropriate
confirmatory diagnosis of an accessory spleen need to be discussed.
CT remains the mainstay for diagnosis of accessory spleen and
therefore, familiarity with its features is helpful in the differential
diagnosis [1,7]. Contrast-enhanced ultrasound (CEUS), regarded as
the other effective method will usually provide valuable additional
information about splenic abnormalities, allowing a definitive or
short differential diagnosis to be made [8]. Moreover, 99mTechne-
tium sulfur colloid scintigraphy provides an easily accomplished
method to establish the identity of ectopic splenic and hepatic
tissues [2,7]. Finally, laparoscopy has an important role in the
identification and management of accessory spleens [9].
In the end, this is the first report of huge accessory spleen
(diameter > 10cm) in the English medical literature. In spite of its
low occurrence, clinicians should examine patients with accessory
 B. Zhuang et al. / International Journal of Surgery Open 6 (2017) 19e21
spleen in mind to avoid unnecessary laparotomy, especially in cases
involving liver cirrhosis and hypersplenism.
4. Conclusion
Such a huge accessory spleen is rare, to a certain extent, it is
difficult to make a definite diagnosis. CT, CEUS, 99mTechnetium
sulfur colloid scintigraphy and laparoscopy may be the reliable
methods for the diagnosis. If clinicians are familiar with its char-
acter, unnecessary treatment can be avoided.
Conflict of interest
The authors have no relevant financial interests or personal af-
filiations in connection with the content of this manuscript.
Funding
This study was financially supported by the key project grant
from the Medical Science Project.
Ethical approval
This study was approved by the Committee for Ethical Affairs.
21
Appendix A. Supplementary data
Supplementary data related to this article can be found at http://
dx.doi.org/10.1016/j.ijso.2017.02.002.
References
[1] Halpert B, Gyorkey F. Lesions observed in accessory spleens of 311 patients. Am
J Clin Pathol 1959;32:165e8.
[2] Mortele  KJ, Mortele
 B, Silverman SG. CT features of the accessory spleen. AJR
Am J Roentgenol 2004;183:1653e7.
[3] Gayer G, Zissin R, Apter S, Atar E, Portnoy O, Itzchak Y. CT findings in congenital
anomalies of the spleen. Br J Radiol 2001;74:767e72.
[4] Mishin I, Ghidirim G. Accessory splenectomy with gastroesophageal
devascularization for recurrent hypersplenism and refractory bleeding
varices in a patient with liver cirrhosis: report of a case. Surg Today
2004;34:1044e8.
[5] Agha RA, Fowler AJ, Saetta A, et al. The SCARE Statement: consensus-based
surgical case report guidelines. Int J Surg 2016;34:180e6.
[6] Gardakis S, Pitiakoudis M, Sigalas I, et al. Infarction of an accessory spleen
presenting as acute abdomen in a neonate. Eur J Pediatr Surg 2005;15:
203e5.
[7] Beahrs JR, Stephens DH. Enlarged accessory spleens: CT appearance in post-
splenectomy patients. AJR Am J Roentgenol 1980;135:483e6.
[8] Omar Asha. Simon Freeman. Contrast-enhanced ultrasound of the spleen. Ul-
trasound 2016;24(1):41e9.
[9] Vaos G, Mantadakis E, Gardikis S. The role of laparoscopy in the identification
and management of missing accessory spleens after primary splenectomy: a
case report and literature review. J Indian Assoc Pediatr Surg 2016;21(4):
196e8.