Situs inversus with cholelithiasis.
KA Pathak, R Khanna, N Khanna
Department of Surgery, Banaras Hindu University, Varanasi, India., India
K A Pathak
Department of Surgery, Banaras Hindu University, Varanasi, India.
Situs inversus totalis is a form of heterotaxia which is usually detected accidentally while investigating for any associated condition. If undetected, this condition can create a diagnostic puzzle. We report one such case in which situs inversus was associated with cholelithiasis.
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Pathak K A, Khanna R, Khanna N. Situs inversus with cholelithiasis. J Postgrad Med 1995;41:45-6
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Pathak K A, Khanna R, Khanna N. Situs inversus with cholelithiasis. J Postgrad Med [serial online] 1995 [cited 2022 May 26 ];41:45-6
Available from: https://www.jpgmonline.com/text.asp?1995/41/2/45/499
Situs inversus viscerum can be either total or partial. Total situs inversus, also termed as mirror image dextrocardia, is characterised by a heart on the right side of the midline, aorta turning to the right and reversed position of all cardiac chambers. The liver and the gall bladder are on the left side. The patients are usually asymptomatic and have a normal longevity. But at times this condition may be associated with other ailments, which may lead to its chance defection either preoperatively or as an intraoperative surprise.
LD, a thirty years old right handed married lady presented with increasingly frequent attacks of mild to moderate pain in the left upper abdomen for 2 years, along with nausea and occasional vomiting. During these episodes of the pain, the patient used to have mild fever without chills. The patient had three healthy children and her married life had been normal. She was unaware of this anomaly until she was informed about it. The patient was in good general condition. Examination of the cardiovascular system revealed the apex beat to be in the right fifth intercostal space. The heart sounds were best heard over the right lower chest. There was mild tenderness in the left hypochondrium and the adjoining epigastrium.
Hematological and biochemical parameters were within the normal range. Chest xray showed dextrocardia with a right-sided aortic knuckle. Inversion of the lead I and transposition of the leads I and II was observed on ECG which was corrected by the reversal of the leads. Ultrasonography confirmed the suspicion of situs inversus by demonstrating the presence of a left sided liver and a left sided gallbladder containing multiple calculi. The spleen was on the right side with normal echotexture.
The patient underwent elective cholecystectomy under general anaesthesia through a left sub-costal incision. The liver and the gallbladder were found on the left side. The postoperative course was normal.
Situs inversus was first described by Aristotle in animals and by Fabricius in humans. Its incidence has been reported to vary widely between 1:4,000 to 1:20,000. Congenital heart diseases are seen in 3% of situs inversus totalis. The exact aetiology remains obscure. However, attempts have been made to explain this on the basis of a complex gene with variable expression. The underlying genetic defect is thought to occur either at conception or within two weeks of embryonal life.
Situs inversus usually remains undiagnosed, as exemplified by the present case, unless it is diagnosed accidentally while investigating for another associated ailment. There have been isolated reports of associated peptic ulcer perforation amoebic liver abscess, acute cholecystitis, cholelithiasis and intestinal obstruction with situs inversus. Cholelithiasis with situs inversus usually presents with pain in either hypochondrium or epigastrium and may mimic hiatus hernia, peptic ulcer disease or pancreatitis. Therefore, all attempts should be made to detect cholelithiasis and situs inversus preoperatively by Xray of the chest, ultrasonography and CT scanning. Prior to the widespread use of these techniques, the rate of preoperative diagnosis was 55%, intraoperative was 32% and in 13% of cases the preoperative suspicion was confirmed intraoperatively. However, these techniques have enabled better delineation of intraabdominal pathology, thus reducing the chances of an inappropriate exploration.
Once the diagnosis of cholelithiasis associated with situs inversus is established, the subsequent cholecystectomy can be easily performed from either side of the table. Cholecystectomy may be performed through a liberal incision so as to perform a critical 3, exploration of abdomen for any developmental anomalies. If detected, they should preferably be managed simultaneously, thereby preventing a subsequent laparotomy. Some surgeons advocate an incidental apppendicectomy at the same time to avoid any diagnostic dilemma arising out the abnormal position of appendix, which may cause pain in the left or right iliac fossa.
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