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|Year : 1977 | Volume
| Issue : 2 | Page : 89-90
Situs inversus totalis with calculus cholecystitis and mucinous cystadenomas of ovaries
PG Rao, RN Katariya, S Sood, PLNG Rao
Department of Surgery, Postgraduate Institute of Medical Education and Research, Chandigarh-160011, India
P G Rao
Department of Surgery, Postgraduate Institute of Medical Education and Research, Chandigarh-160011
Source of Support: None, Conflict of Interest: None
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.
|How to cite this article:|
Rao P G, Katariya R N, Sood S, Rao P. Situs inversus totalis with calculus cholecystitis and mucinous cystadenomas of ovaries. J Postgrad Med 1977;23:89-90
|How to cite this URL:|
Rao P G, Katariya R N, Sood S, Rao P. Situs inversus totalis with calculus cholecystitis and mucinous cystadenomas of ovaries. J Postgrad Med [serial online] 1977 [cited 2020 Feb 26];23:89-90. Available from: http://www.jpgmonline.com/text.asp?1977/23/2/89/42800
Situs inversus totalis is a rare congenital condition occurring in 1 in 5,000 to 1 in 10,000 of all births and in this there is mirror image transposition of both abdominal and thoracic viscera. It is compatible with normal life and any disease process can effect persons with this condition. Amoebic liver abscess,  chronic duodenal ulcer,  acute appendicitis,  adenocarcinoma of caecum,  jejunal and ileal atresia  have all been reported with situs inversus totalis. Chronic cholecystitis and cholelithiasis has also been documented. We have been able to trace only 26 cases of cholelithiasis ,,,, 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.  Therefore, more than half of the cases of acute appendicitis in situs inversus totalis present with symptoms and signs in right iliac fossa.  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. 
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. 
| :: 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. |
[Figure 1], [Figure 2]