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805

Pictorial
1

Essay

Radiologic
Wylie J. Dodds,1

Imaging
Andrew J. Taylor,

of Splenic
Scott J. Erickson,

Anomalies
Edward T. Stewart, and Thomas L. Lawson

Knowledge of the anatomy, embryology, and congenital anomalies of the spleen is needed in order to avoid pitfalls in the interpretation of abdominal imaging studies such as CT and sonography. For this reason, this pictorial essay illustrates the anatomy, embryology, and radiologic images of congenital anomalies of the spleen.

along the superior border of the splenic hilum (Fig. 3). Short gastric the gastrosplenic ligament.

pancreas [4] to enter the vessels are located within

Embryology
In a 4- to 5-week embryo (Fig. 4A), the stomach is suspended by a ventral mesentery (ventral mesogastrium) and dorsal mesentery (dorsal mesogastrium). During the fifth week, the spleen develops in the dorsal mesogastrium from mesenchymal cells that migrate between the leaves of the

Anatomy
As the largest unit of lymphatic tissue in the body, the spleen is a solid alimentary-tract organ located in the lateral posterior part of the left upper abdomen [1 ]. It is generally shaped like a curved wedge with a convex superior diaphragmatic surface, a gastric impression on its upper medial border,

a renal impression

along

its lower

medial

margin,

and, freGastric Impression

quently, a colonic impression at its inferior margin (Fig. 1). The pancreatic tail often abuts against and indents the spleen at its hilum (Fig. 2). In supine adults, the spleen lies in the left subphrenic space, posterolateral to the stomach. Its anterior margin seldom projects ventral to the anterior axillary line, while its blunt posterior border generally lies within 3-4 cm of the lumbar spine (Fig. 2). The long axis of the spleen parallels the tenth rib. The left lateral pulmonary diaphragmatic recess frequently extends caudad as far as the inferior border of the spleen. This fact should be considered when performing
percutaneous biopsy or drainage of splenic lesions. The in-

Ren

Impressn

Pancreatic

Impressen

- Anterior

Margin

ferior splenic border often nestles against and is supported by the phrenocolic ligament. Located within the dorsal gastric mesentery, the spleen divides this mesentery into the gastrosplenic and splenorenal ligaments [2, 3]. Thus, the spleen and its ligaments form the lateral margin of the lesser peritoneal sac [3]. The splenic vessels, lymphatics, and nerves course
Received
1

Fig. 1.-Drawing

of splenic anatomy.

is a right anterior oblique view. and constitutes about 30-40%

Spleen seen from its medial border Note that splenic hilum is vertically oriented of vertical height of spleen.

April 2, 1990; Department

accepted

after revision

May 20, 1990. College of Wisconsin, Ave., Milwaukee, Milwaukee, Roentgen WI 53226. Address reprint requests to W. J. Dodds, Department of

All authors:

of Radiology, Lutheran

the Medical Hospital, 9200

Radiology,

Froedtert

Memorial October

W. Wisconsin

WI 53226. Ray Society

AJR 155:805-810,

1990 0361 -803X/90/1

554-0805

© American

This anatomy provides a direct pathway processes of for pan- inflammatory or neoplastic creatic tail to invade spleen. 2A). As in this example. normal spleen has a kidney bean or boomerang shape on cross section. Variation exists in the splenorenal ligament. is commonly located within the splenorenal ligament and abuts the splenic hilum (Fig. Commonly. A. the spleen is the only alimentary-tract structure that the gut or one of its anlagen. pancreatic tail commonly passes through splenorenal ligament to abut spleen at its hilum. 4C).806 DODDS ET AL. mesentery and coalesce [2]. 3. 7). The splenorenal ligament may persist narrow strut that creates a small bare area over margin of the spleen (Fig. inflammatory or neoplastic processes of the pancreatic tail may extend directly into the spleen (Fig. 5) or as a long mesentery. as a short. A = aorta. B. 6). the to the left while the liver enThus. Thus.-CT images of normal spleen from two patients. lies against the most dorsal part of the mesogastrium with the posterior and fuses a short (Fig. the dorsal mesogastrium the lesser peritoneal sac (Fig. whereas anterior margin of spleen rarely projects ventral to anterior axillary line. vC = vena cava. or lobulations that persist from fetal lobulations should not be mistaken for splenic fractures due to trauma. The splenic vessels lie just cephalad to the pancreas and enter the spleen depending the posterior Congenital Anomalies through the splenorenal ligament (Fig. AJR:155. peritoneum to leave peritoneum. called the splenorenal ligament of the pancreas. Rounded medial margin of posterior spleen is commonly within 3-4 cm of spine. Relationship of pancreatic tail to spleen. notches. stomach enlarges and rotates larges and rotates to the right. the extent of fusion of the mesogastrium with on Splenic clefts. Fig. Sp = spleen. residual mesentery. P = pancreas. It comprises a posterior part dorsal to stomach and an anterior part lateral to stomach. swings to the left [3] to form does not develop directly from During the next 4-5 weeks. October 1990 Fig. 3). Location of spleen in left upper quadrant. The location of the original mesentery is evident by the course of the splenic vessels that lie within the secondary anterior space of the left retroperitoneum [5]. PV = portal vein. the medial The tail 4B). 2. Clefts usually occur on the diaphragmatic surface . Because the pancreatic tail is located within the splenorenal ligament.-Splenic artery (SA) and splenic vein (SV) are seen to course along cephalic margin of pancreatic body to enter spleen at its hilum. Subsequently. St = stomach. located within the dorsal mesentery of the duodenum at a level slightly caudad to the spleen (Fig.

(Modified and reprinted from Dodds et al. October 1990 SPLENIC ANOMALIES 807 A Fig. Almost all of posterior part of dorsal mesogastrium has fused with posterior peritoneum to leave a short splenorenal ligament (4). A short splenorenal ligament (straight arrows) contains splenic vessels. 6.-Upper abdomen in 8-week embryo. Mature fetus. Ant.). Spleen develops within dorsal mesogastrium while liver develops within ventral mesogastrium. C. Ventral pancreas (VP) anlage is seen slightly caudad to dorsal pancreas.AJR:155.) fetus. 4 = splenorenal ligament. 2 = gastrohepatic ligament. As liver enlarges and swings to right. Stomach is supported by a dorsal mesentery (dorsal mesogastrium) and ventral mesentery (ventral mesogastrium). Liver (L) swings to right C Fig. L = liver. Gastrosplenic ligament. 5-week embryo. 5. spleen. B Fig. [5]. = posterior.-Schematic cross sections of upper abdomen of embryo and while stomach (St. A. Normally. 4. This ligament normally lies against and fuses with posterior peritoneum to form short splenorenal ligament. 8-week embryo. K = kidney. and dorsal pancreas (DP) swing leftward. dorsal duodenal mesentery folds against and fuses with postenor peritoneum so that pancreatic body becomes a secondary retroperitoneal structure. B. 3 = gastrosplenic ligament.-Abdominal CT scan of splenorenal ligament of patient with recurrent pancreatitis and ascites. Spleen mesogastrium mesogastrium into gastrosplenic (4). Failure of this fusion leads to a long splenic mesentery and a wandering spleen. (Modified and reprinted from Dodds et al. Spleen and dorsal pancreas are in common dorsal mesentery of stomach and duodenum. = anterior. Liver divides ventral mesogastrium divides dorsal into falciform (1) and gastrohepatic (2) ligaments. spleen and stomach swing leftward to form lesser peritoneal sac. [3]. and splenorenal ligament form lateral margin of lesser peritoneal sac. Sp = spleen. I = falciform ligament.) . Post. spleen (Sp). part of which will become ligament (3) part of dorsal splenorenal ligament. S = stomach. This embryologic anatomy explains why pancreatic tail commonly runs through splenorenal ligament to abut on splenic hilum. A 4-cm pseudocyst is seen interposed botween pancreatic body and stomach. Ascitic fluid in greater peritoneal cavity and lesser peritoneal sac outlines ruffled gastrosplenic ligament (curved arrow).

Occasionally. Consequently. Capillary phase. an accessory spleen may be embedded along the greater curvature of the stomach to form an intramural mass.5 cm in diameter. of the spleen medial part bus splenic (Fig. 9. Because accessory spleens frequently overlap the pancreas and show a homogeneous stain on arteniography. 9). Fig. Arterial phase. On CT. or within the gastrosplenic ligament or omentum. along the course of the splenic vessels. B. 4B) may not fuse with the dorsal peritoneum and thereby persist as a long mesentery. whereas spleen and may (Fig. Accessory spleens may be single or multiple. 6). 10).808 DODDS ET AL. 1 1). pancreas passes through splenorenal ligament to abut against hilum of spleen.-Example of splenic lobulation on a celiac arteriogram. Commonly. disease processes of pancreatic tail have access to a direct pathway to spleen. 1 2). on splenculi.-Disease invading spleen via splenorenal ligament on contrast-enhanced CT scans. but there are seldom more than six (Fig. Spleen exhibits a large lobulation (arrow) at its mediosuperior border. 7. they must be distinguished from an isletcell pancreatic tumor on angiography. 6) generally distinguish them from enlarged lymph nodes. Two congenital clefts (arrows) are seen. Pseudocyst (arrow) originating from pancreatic tail has extended into lower margin of splenic hilum. Some of the artery lobulations occur along the be supplied by an anomalobulations cause a worn- a splenectomy spleens should the main spleen is done for a blood dyscrasia. Accessory segmental artery (arrow) supplies upper medial margin of spleen. Characteristically. In some individuals. they are smooth with a round or oval shape and are about 1 . Definitive identification of an some extrinsic gastric impression. 8). are present in about 1 0% of the population. Oblique views may be required. Carcinoma originating from tail of pancreas has invaded hilar area of spleen (arrows).-Example of splenic clefts on contrastenhanced abdominal CT scan. Metastatic areas of low attenuation are seen in liver. which labels splenic reticuloendothelial cells as well as those in the liver. Frequently. In some in- . Other confirmatory evidence of the diagnosis is that the splenic vessels pass to the ectopic mass. B. or hepatic radionuclide scanning discloses that a normal spleen is not present in its typical location. A B Fig. but they may occur anywhere in the abdomen. the dorsal part of the gastric mesentery (Fig. A. their characteristic appearance and location within the embryologic dorsal mesenteny of the stomach and pancreas (Fig. When accessory spleen is accomplished by a liver-spleen scan with technetium sulfur colloid. A. One or more accessory spleens. October 1990 Fig. Accessory spleens are most often located in the vicinity of the splenic hilum (Fig. 8.” which is highly mobile and may rotate to the center of the abdomen (Fig. A wandering spleen is often discovered as an asymptomatic mass in the anterior abdomen. all accessory be removed because they may enlarge once is removed.0-1 . Diagnostic evaluation by sonography. AJR:155. CT. This anomaly results in a “wandening spleen. the tail of the pancreas lies within the long splenic mesentery because of the proximity of the dorsal mesentery of the pancreas to the dorsal mesentery of the spleen during the first trimester of gestation (Fig.

Multiple accessory spleens. on its long ische- torsion causes mia. 1 1. a normal spleen. a wandering Such spleen onset undergoes vascular a volvulus compromise. Three additional accessory spleens main spleen was absent. is seen on left side of abdomen. ischemic spleen. On this CT image. 13. which occurs mainly in males. just caudad to liver. The asplenia type. representing infarcted wandering spleen.by 3-cm mass (straight arrows) shows same echogenic characteristics as spleen. 10. Contrast-enhanced CT scan bolow level of liver. A. Several congenital cardiosplenic syndromes consist of complex cardiac malformations. Ventral wandering spleen (arrow) is seen in midline.-Accessory spleens on contrast-enhanced abdominal CT scans. Accessory spleen. coronal view obtained by placing transducer head between ninth and tenth ribs in mid axillary line. Also. The injection (Fig. B. whereas spleen is not imaged. Both may occur be associated The with situs type ambiguous is associated of the gastrointestinal with cyanotic splenic anomalies. does not show radioactive isotope scan (Fig. Unenhanced mass (arrows). has of a galltypes may heart left-sided features consisting of absence and bilateral left lung morphology. has bilateral right-sided features of a horizontal midline liver. Anterior view shows normal-appearing liver in upper abdomen. stances.AJR:155.-Ectopic scintigram obtained soft midline mass wandering spleen on hepatic to evaluate asymptomatic. was confirmed on abdominal CT. asplenic . in middle abdomen that was discovered on a routine physical examination. had same attenuation as main spleen.-Torsion and ischemic infarction of a wandering spleen. 12. On abdominal CT. mesentery. are seen in fat caudal levels. and is identified adjacent to inferior margin of splenic hilum. Fig. three accessory spleens (arrow) of gastrorenal ligament. Accessory spleen is located within original dorsal mesentery to stomach or duodenum. 1 3A). Spleen acts as sonographic window. This mass. predominant in females. type. A sharply defined 2. October 1990 SPLENIC ANOMALIES 809 Fig. B. Anterior view shows normal-appearing liver in upper abdomen. judged to bo an accessory spleen. A 4 Fig. Splenic vein (curved arrow) is seen entering hilum of spleen. (Fig. and bilateral right lung morphology.5-cm mass. Howell-Jolly bodies in the peripheral blood resuIting from asplenia. Solitary accessory spleen (arrow) is located lateral to kidney and caudad to main spleen (not shown). This patient did not have congenital were present at more heart disease. 1 3B). Hepatic scintigram. polysplenic bilateral bladder tract. A normal spleen is not seen in left upper quadrant. the ischemic spleen does not enhance after contrast as well uptake as the on an that and intermediate situs. a smooth 1. 14). A.-Accessory spleen on slightly oblique Fig. and the acute of abdominal pain.

the developing anlage of the spleen and left gonadal anlage lie in close apposition (Fig. such as a splenectomy or oophorectomy. epididymis. Importantly. Upperdigestivetract. REFERENCES 1 . The developing human: clinically oriented ed. or mesovarium.810 DODDS ET AL. 15) or herniation. et al. 28th ed. Anatomy Febiger.15:276-298 reasons. this anatomic anomaly must be considered when doing a percutaneous puncture for placement of a nephrostomy tube in the left kidney. Philadelphia: Saunders. The spleen or spleens be sought mainly in the upper quadrant ipsilateral stomach because the spleen develops in the dorsal mesentery. Existence of the splenogonadal syndrome is generally documented as an unsuspected finding in individuals undergoing surgery for other lateral recess persists that is filled by the spleen or intestine [5]. Darweesh RMA. Dodds WJ. Fig. a normal single spleen is present in the left upper abdomen. ed. 16. Anatomy of the human body. In this case. 14. AJR 1986. part 1 . In the continuous type of splenogonadal anomaly. Lawson TL.-Polysplenic cardiosplenic syndrome in child with complex congenital cardiac anomalies and polysplenism. ovary. should to the gastric is the identified on sonography in utero or diagnosed Children or young adults may exhibit congenital eventration (Fig. A. Dodds WJ. AJR 1985. Semin NucI Med 1985. Fig. Another splenogonadal tween anomaly wherein involving the spleen posterior location of the spleen an association exists be- 16).147: 1155-1161 6. ed. Liver-spleen scintigram. diaphragmatic A relatively congenital syndrome. In the first trimester of pregnancy. the left gonadal anlage begins to migrate toward the pelvis. At about 9 weeks of gestation. Goss CM. 4) when partial fusion occurs between the dorsal mesogastrium and left posterior penitoneum. 1962 5.to 6-cm masses (asterisks) representing multiple spleens are seen Immediately ventralto kidney.-Spleen (asterisk) located in eventration of left hemidiaphragm is seen on abdominal CT scan obtained to exclude malignancy in 20year-old patient. New York: Ciba. A discontinuous type of splenogonadal anomaly occurs when some splenic tissue migrates with gonadal tissue. Two round. A. Sty JR. Three spleens (asterisks) are seen in left upper abdomen. Philadelphia: Lea & 2nd and 2. In: OppenheimerE. The retropentoneal spaces revisited. Taylor imaging of the lesser peritoneal sac. Congenital herniation of the left hemidiaphragm may involve the spleen as well as the intestine. Digestive system. Netter FH. B. The spleen: development and functional evaluation.144:567-575 4. TheCiba collection of medical illustrations. Such hemiations may be .-Anomalous bohind 15 16 location of spleen (arrow) left kidney. 1977 3. Stewart ET. ed. disease and a poor prognosis. Parasagittal sonogram through left kidney. common congenital may occur anomaly behind the is a pronounced left kidney (Fig. left-sided cryptorchidism is present. vol 3. a cord of splenic or fibrous tissue connects a normally located spleen with the testes. 15. 1966 embryology. in the neonate. Diaphragmatic eventration was judged to bo congenital. Lawson TL. This circumstance when a deep penitoneal splenic and gonadal tissue [6]. AJR:155. but a normal-sized spleen was absent. Liver appears normal. October 1990 Fig. 5. In males. A third spleen was identified just cephalad. Conway JJ. Moore KL. Foley WD.