[Case report] Unusual Cause of Bowel Obstruction in Adolescent: Wandering Spleen with Internal Hernia and Ectopic Left Kidney. A Case Report.

Background : A wandering spleen is a condition in which the spleen, located in the upper left abdomen, becomes dislocated from its normal position. Although literature on wandering spleen exists, there is very limited literature on wandering spleen causing internal hernia. We present a novel case of wandering spleen, left ectopic kidney with internal herniation leading to intestinal obstruction. Case Presentation: 13-year-old female presented with abdominal pain and imaging showed a wandering spleen with cyst, left ectopic kidney, internal herniation leading to intestinal obstruction. Barium enema showed normal flow of contrast and patient was managed conservatively. Conclusion : Wandering spleen with internal hernia causing transient obstruction are rare and the radiologist needs to know the imaging findings to make a correct diagnosis. To serve that purpose we present such a unique case.


Background
Wandering spleen with splenic cysts are unusual [1] . The wandering spleen can undergo torsion or internal herniation as in this case report. That can lead to subtotal or total intestinal obstruction. They can be associated with ectopic kidney that can have internal abnormalities like dilatation of the pelvicalyceal system. Although literature on wandering spleen exists, there is very limited literature on wandering spleen causing internal hernia. We present a novel case of wandering spleen, left ectopic kidney with internal herniation leading to intestinal obstruction.

Case Presentation
Qeios, CC-BY 4.0 · Article, June 5, 2023 Qeios ID: THW66N · https://doi.org/10.32388/THW66N 1/9 13-year-old female came with 1 day history of abdominal pain, diarrhea followed by constipation and 3 episodes of nonbloody non bilious vomiting. Clinically she was suspected to have chronic constipation, celiac disease or lactose intolerance. A computed tomography of the abdomen was performed that revealed wandering spleen, left ectopic kidney with internal hernia leading to colonic obstruction [ Fig.1 Fig.6]. The ovarian hemorrhagic cyst had resolved. Patient was advised to continue on the prescribed medical management and follow up. Splenectomy was avoided as splenectomy itself has its complications [2] .

Discussion
The wandering spleen is a condition in which the spleen, located in the upper left side of the abdomen, becomes dislocated from its normal position [3] . This can occur as a result of a birth defect or due to trauma. Symptoms of a wandering spleen can include abdominal pain, a feeling of fullness or bloating in the abdomen, and a change in the position of the spleen. The spleen may also become enlarged and may be felt as a mass in the abdomen.
Internal hernia is a condition in which a section of the intestines or other abdominal organs protrudes through a defect or weakness in the mesentery [4] . There are several different types of internal hernias, depending on the location of the defect. The most common type is the paraduodenal hernia, which occurs when a portion of the small intestine protrudes through the fosaa of Landzert or the fossa of Waldeyer. Internal hernia can sometimes cause bowel obstruction. The clinical diagnosis of internal hernia is difficult and computerized tomography and barium studies play a very significant role [5] .
Treatment for an internal hernia depends on the severity of the condition and the underlying cause. In mild cases, treatment may involve medications to control symptoms and dietary changes to reduce the risk of bowel obstruction. In Qeios, CC-BY 4.0 · Article, June 5, 2023 Qeios ID: THW66N · https://doi.org/10.32388/THW66N 8/9 more severe cases, surgery may be necessary to repair the defect in the abdominal wall and prevent further complications. It is important for individuals with an internal hernia to receive prompt and appropriate treatment to prevent complications and maintain overall health. Regular follow-up with a healthcare provider is also important to monitor the condition and ensure that it is properly managed.

Conclusions
We present an unusual case of wandering spleen with splenic cyst causing internal herniation with transient intestinal obstruction. Given the transient nature of intestinal obstruction, and inherent complication of splenectomy surgery was deferred. Patient was managed medically and did well.