Splenodiaphragmatic interposition of the splenic flexure of colonVK S Nalamolu, A Chatterjee
Department of Radiology and Imaging, Tata Medical Center, Kolkata, West Bengal, India
Correspondence Address: Source of Support: None, Conflict of Interest: None DOI: 10.4103/jpgm.jpgm_2_22
Source of Support: None, Conflict of Interest: None
Abnormalities of rotation and fixation of the colon during embryological development cause colonic malposition; some of them are of clinical importance. Knowledge of such variations can aid in their detection at cross-sectional imaging and avoid unnecessary complications. In this report, we are discussing splenodiaphragmatic interposition of the splenic flexure of the colon and possible complications if unnoticed.
A 77-year-old man with known hepatocellular carcinoma (HCC) underwent a computed tomography (CT) scan of the thorax and magnetic resonance imaging (MRI) of the upper abdomen for staging. CT demonstrated that the splenic flexure of the colon was interposed between the spleen and the left kidney anteriorly and left dome of the diaphragm posteriorly. The superior extent of the splenic flexure of the colon reached high in the left hypochondrium, causing effacement of the left posterior costophrenic recess [Figure 1].
Distal transverse colon, splenic flexure, and descending colon are developed from the hindgut. Rotation and fixation of the gut follow a specific and coordinated process. Following a rotation of the midgut, the jejunal loops return to the abdominal cavity. This displaces the hindgut laterally to the left and fixes the dorsal mesentery of the splenic flexure to the posterior abdominal wall. This gives rise to the phrenicocolic ligament that extends from the splenic flexure of the colon to the parietal peritoneum covering the undersurface of the left dome of the diaphragm. Normally splenic flexure of the colon lies anterior to the inferior pole of the left kidney and is more superior, more acute, and less mobile than the hepatic flexure of the colon. Abnormalities in the rotation and fixation of the colon and caudal displacement of the spleen due to diseases such as emphysema can lead to malposition of the splenic flexure of the colon.,, Retrosplenic colon can be seen in association with renal agenesis, renal ectopia, post-nephrectomy, agenesis of the diaphragm, or congenital diaphragmatic hernias., The prevalence of retrospleinc or splenodiaphramatic interposition of the colon can be up to 0.3%.
The interposition of the colon between the spleen and diaphragm represents a clinically important anatomical variant during a certain surgical procedure and percutaneous radiological intervention. Spleen is located anterior and medial to the left 9th, 10th, and 11th ribs and separated from them by the diaphragm and the costodiaphragmatic recess of the pleura. The pleural recess extends up to the 10th rib in the mid-axillary line and up to the 12th rib posteriorly. The left kidney extends from T12 to L3 vertebral bodies. Percutaneous intervention procedures such as percutaneous needle biopsy of spleen or kidney, percutaneous nephrostomy, and left pleural aspiration should be cautiously performed in the patients with splenodiaphramatic interposition because of the risk of perforation of the colon. Colonic perforation can cause peritonitis, colitis, and pleuritis. In patients with this variation, there is a risk of injury to the colon during splenectomy.
Splenodiaphramatic interposition of the colon is an important anatomical variant and can be confidently identified in cross-sectional imaging. Identification of this variant will avoid unnecessary perforation of the colon during the percutaneous biopsy, left pleural aspiration, and splenectomy.
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