Acute Abdomen in Situs Inversus Totalis

Abstract

Introduction: Situs Inversus (SI) is a rare autosomal recessive or an X-linked condition resulting in an abnormal mirror image abdominal organs position with a rate of 0.01% among the population. When SIT individuals present clinically with abdominal pain, the diagnosis can be challenging to make without any advanced imaging modality, as the symptoms are often nonspecific and do not align with the normal anatomical positioning of the abdominal organs, and this could cause a delay in diagnosis and management. In this paper, we discuss the challenging pathway in diagnosing and managing surgical abdominal emergencies in patients with situs inversus. Case Presentation: We present a 22-year-old male medically free who came to the emergency room with abdominal pain, vomiting, and constipation following an appendectomy. The patient had undergone laparoscopic appendectomy in another hospital for perforated appendicitis almost one month ago, during the postoperative period, an abdominal drain was kept for a few days until discharge. Computed tomography (CT) was done and showed a case of situs inversus totalis (SIT) with a completely mirrored image of the normal abdomen orientation. The decision was made to admit the patient for a trial of conservative management as treatment for adhesive bowel obstruction. Patient was kept nil per os (NPO) and on intravenous fluids (IVF), with electrolyte correction and frequent physical examination reassessment. A gastrograffine challenge test was done. Patient ingested around 100 ml of hyperosmolar contrast mixed with water. During re assessment patient had passed bowel motion due to the laxative effect of gasrtograffine and was stable and fit for discharge. Since it is known that patients with SIT might have an undiagnosed congenital heart disease, cardiology consultation was sent, and ECHO (Echocardiography) was arranged. ECHO revealed ejection fraction (EF) of 50%, reduced left ventricular (LV) function, tricuspid regulation, and mitral regurgitation. Patient was started on Bisoprolol 1.25 mg, Lisinopril 2.5 mg, and Dapagliflozin 10 mg for cardiomyopathy. Discussion: SIT is a rare clinical finding in the day-to-day practice however when presented, diagnosis and surgical approach can be challenging. Our aim in this paper is to discuss proper examination of patients with abdominal pain and SIT, the need for cardiac screening in SIT, and surgical approaches in acute abdomen and SIT. The location of the pain in acute appendicitis with anomalies varies, but almost 70% of patients had left lower quadrant pain, other presented with right lower quadrant pain, peri-umbilical, and diffuse abdominal pain. Identifying anomalies during acute settings can be difficult, in one study; preoperative diagnosis was made in 83.6% of cases based on radiological findings, while 16.4% were identified during surgery. The diagnosis of acute appendicitis in such cases can often be complex, and delay in surgical management may contribute to increased morbidity and mortality. Misdiagnosis is more prevalent in cases where patients present with atypical symptoms, such as pain localized to unexpected areas. The occurrence of acute appendicitis in conjunction with situs inversus totalis (SIT) or mirror image malformation (MM) is uncommon, with an incidence ranging from about 0.016% to 0.024%. Regarding the appropriate surgical technique in dealing with patients diagnosed with anatomic anomalies. Laparoscopic exploration is a useful tool when clinical and radiological findings are inconclusive, especially when the appendix is in an unusual anatomical location. This method eliminates the need for large incisions and provides easier access for the trained surgeon. Laparoscopy allows for a thorough examination of the entire abdominal cavity, helping to confirm the initial diagnosis and identify any other pathological conditions. There is no fixed protocol for trocar placement in these unusual cases, and the surgeon should adjust port positioning based on key laparoscopic principles, such as triangulation and ergonomics. Conclusion: We suggest detailed history taking and examination in patients with acute abdomen and unclear diagnosis. Always remember to keep a broad differential diagnosis in mind. We recommend screening for any cardiac anomalies in patients with SIT since congenital heart disease is observed in 3% to 5% of these cases. And lastly, to not hesitate with liberal use of laparoscopic exploration as a diagnostic tool in unclear cases of abdominal pain.