Situs inversus totalis with calculus cholecystitis and mucinous cystadenomas of ovaries

Correspondence Address:
P G Rao
Department of Surgery, Postgraduate Institute of Medical Education and Research, Chandigarh-160011
India

Source of Support: None, Conflict of Interest: None

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PMID: 614420

An uncommon case of cholelithiasis and cholecystitis with mucinous cystadenomas of ovaries in situs inversus totalis is presented along with its clinical implications. Clinical and radio­logical signs in diagnosis of situs inversus totalis are discussed.

^{[2],[6],[7],[8],[9]} with situs inversus totalis in English literature, and the rarity of this condition has prompted us to report this case.

:: Case report

A 56 year old female patient who was known to have true dextrocardia, pre­sented as an emergency with colicky pain in the left hypochondrium of 18 hours' duration. On examination, she was found to be anicteric, obese lady with normal pulse rate and blood pressure. Abdominal examination showed a globu­lar, 4 x 3 cms. tender mass in the left hypochondrium which was moving with respirations. Cardiovascular system re­vealed the apex beat in the right fifth in­tercostal space with heart sounds best heard on the right side.

A clinical diagnosis of situs inversus totalis with left sided acute cholecystitis was made, which was later confirmed by chest X-ray See [Figure 1] on page 88B, barium meal examination and oral cholecystogram See [Figure 2] on page 88B which revealed a functioning left sided gall bladder with multiple filling defects.

The patient was eventually explored through an upper abdominal midline in­cision. Falciform ligament was found to be going to the left side and there was complete transposition of abdominal viscera. The stomach and spleen were on the right side. Gall bladder was on left side and contained multiple stones. The common bile duct was situated to the left of the midline and was of normal size. Ileocaecal region was in the left iliac fossa and sigmoid colon was in the right iliac fossa. Both ovaries were stud­ed with multiple cysts. Operative cho­langiogram, cholecystectomy, appendicec­tomy and bilateral oophorectomy were carried out. Histological examination showed evidence of chronic colecystitis in the gall bladder, chronic appendicitis in appendix and mutinous cystadenomas of both ovaries. Postoperative period of the patient was uneventful.

:: Comments

In situs inversus totalis, though there is transposition of all viscera, innerva­tion remains the same as in normal per­sons. ^[2] Therefore, more than half of the cases of acute appendicitis in situs in­versus totalis present with symptoms and signs in right iliac fossa. ^[2] Unaware­ness of this condition can lead to wrong surgical approach in such cases. From collective review of the symptomatology of 26 cases of cholecystitis with situs in­versus, we found that 60 per cent of cases presented with pain in the left hypo­chondrium, 30 per cent with pain in the epigastrium and 10 per cent with pain in the right hypochondrium. Our case pre­sented with symptoms and signs in the left hypochondrium.

Clinical diagnosis of situs inversus totalis is possible by detecting the apex heat in the right fifth intercostal space with heart sounds better heard on the right of the chest and by detecting liver dullness on the left side. The presence of right testes lower than left in the scrotum has been described as a helpful diagnostic sign in males. ^[2]

Skiagram of the chest showing right sided heart, plain X-ray of abdomen showing stomach bubble under right dome of diaphragm and liver shadow on the left side, and barium meal and enema provide full proof for the diagnosis of situs inversus totalis.

Oral cholecystography with 10 x 12 inch film and exposure on right side can be misinterpreted as non-functioning gall bladder in situs inversus totalis and, therefore, 14" x 17" film of abdomen has been suggested to overcome this diffi­culty. ^[8]

 

:: References

1.	Ansari, Z. A., Skaria, J.. Gopal. M. S., Vaish, S. K. and Rai, R. N.: Situs in­versus with Amoebic liver abscess. J. Trop. Med. Hyg. 76: 169-170, 1973.
2.	Cholst, M. R.: Discrepencies in pain and symptom destribu'ion. Position of the testicles as a diagnostic sign in situs in­versus totalis. Amer. J. Surg. 73: 104­107, 1947.
3.	Etter, L. E.: Left sided gall bladder. Amer J. Roentgenol. 70: 987-990. 1953.
4.	Fonkalsrud, E. W., Tompkins, R. and Clotworthy, W.: Abdominal manifesta­tions of situs inversus in infants and children. Arch. Surg, 92: 791-795, 1966.
5.	Helgerson, L. O., Kuehner, C. R. and Stanley-Brown, E. G.: Acute appendicitis in a child with complete situs inversus. J. Paediat. Surg. 5: 379-380, 1970.
6.	Mayo, C. W. and Rice, R. G.: Situs in­versus totalis. Statistical review of data on 76 cases with special reference to diseases of the biliary tract. Arch. Surg. 58: 724-730, 1949.
7.	Southam, J. A.: Lefi sided gall bladder. Calculous cholecystitis with situs in­versus. Ann. Surg. 182: 135-137, 1975.
8.	Wood, G. and Blalock, A.: Situs inversus totalis and diseases of the biliary tract. Arch. Surg. 40: 885-896, 1940.
9.	Wright, C. B. and Morton, C. B.: Situs inversus totalis with adenocarcinoma of caecum. American Surgeon. 37: 65-66, 1971.

Figures

  [Figure 1], [Figure 2]

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