Situs Inversus Totalis with Left-Sided Appendicitis: A Case Report

Introduction: Left-sided acute appendicitis (LSAA) develops in association with two types of congenital anomalies: situs inversus totalis (SIT) and midgut malrotation (MM). A Left sided appendicitis is an ambiguous and diffi-cult diagnosis to make. Aim: To present a proven case of left-sided acute appendicitis (LSAA) associated with situs inversus totalis (SIT). Case Report: A case of Left appendicitis was evaluated in a 28-year-old Asian male, who presented to our hospital in Feb. 2016, with lower abdominal pain more on left side and suspected diverticulitis or acute appendicitis with unusual appendix location. The patient doesn’t recall any history of abdominal surgery or about situs inversus totalis, abdominal and pelvic ultrasound was done, left iliac fossa appendicitis was diagnosed, Erect chest X-ray including upper abdomen revealed dextrocardia and stomach air on right side (situs inversus totalis), the patient underwent diagnostic Laproscop and Endoscopic resection of the appendix, with no incidents, and then discharged without complications, fol-low visits went unremarkable. Conclusion: The diagnosis of left lower quadrant pain is based on well-established clinical symptoms, physical examina-tion and physician’s experience.


Introduction
Acute appendicitis is a common condition requiring emergency surgery. The diagnosis is based on clinical symptoms, basic radiologic findings and surgeon experience [1] [2]. Approximately one third of patients with acute appendicitis have pain localized outside of the right lower quadrant because of the various Figure 1. (a) and (b) Ultrasonography of abdomen and pelvis, showed situs inversus totalis including reversed position of liver and spleen. The right iliac fossa was examined, the appendix was not visualized but the left iliac fossa showed signs of acute appendicitis, in the form of distended fluid-filled appendix at 12.2 mm in diameter and seen non-compressible with thick wall, no periappendiceal fluid, and no appendicolith seen, the same patient name, the same ID and the same hospital were displayed on the 3 original images provided (all patient identity information will removed in final version).  According to localization of the symptoms, 59 patients presented with left and  14 with right lower quadrant pain, 7 with bilateral lower quadrant pain, 7 with  left upper quadrant pain, 6 with peri-umbilical, and two presented with pelvic pain. With regard to the diagnosis, 49 patients were diagnosed with appendicitis during the pre-operative period, in 19 patients, the diagnosis was established intraoperatively and in 5 postoperatively; 14 patients were previously known to have SIT and/or MM. No information was available in eight patients. Of 95 patients included in this literature review, 13.6% (13 cases) of patients underwent Laparoscopic appendectomy [66].

Discussion
It is important to differentiate LSAA associated with malrotation from that associated with situs inversus totalis, in which every organ, including duodenum, duodenojejunal junction, small and large bowel, cecum, and appendix, is located  [1]. In addition to these features, a left-sided liver and right-sided spleen and stomach serve as clues to the correct diagnosis of situs inversus totalis. Chest X-ray is important to obtain at this point for ruling out situs inversus totalis which may be confused with intestinal malrotation.
More than two-thirds of the left-sided appendicitis is due to situs inversus totalis rather than intestinal malrotation [66].
MM is the term used to describe a spectrum of congenital positional anomalies of the intestine caused by nonrotation or incomplete rotation of the primitive loop around the axis of the superior mesenteric artery (SMA) during fetal life. Although about 80% of cases are diagnosed in patients younger than 1 month, malrotation has also been reported in adults [8]. The incidence of MM cited in the literature varies from 0.03% to 0.5% in live births [1] [3] [9] [10].
The situs inversus may be complete (SIT), when both thoracic and abdominal organs are transposed, or partial, when only one of those cavities is affected [1].
The incidence of SIT reported in the literature varies from 0.001% to 0.01% in the general population [12] [13] [14], whereas the incidence of acute appendicitis associated with SIT is reported to be between 0.016% and 0.024% [5] [13] [14].
In the literature, LSAA occurs between the age of 8 and 63 years and is 1.5-fold more frequent in men than in women [3] [13].
LSAA is a diagnostic dilemma, because the appendix is located in an abnormal position. The differential diagnosis of LSAA may not be promptly established in the emergency setting and is often delayed due to lack of uniformity in the clini- [26] [27]. USG in our case was acurate in diagnsig situs inversus and in depacting non-complicated acute appendicitis because was not fat and bowel distension.
After establishing the diagnosis of SIT or MM, the surgical options are the same as for normal patients [1]. According to the reviewed literature, it was observed that many open and a few laparoscopic procedures have been performed [1] [6] [8] [15]. Laparoscopic appendectomy was first carried out in 1998 by Contini et al. [58] in a 34-year-old male patient with SIT. Since then, laparoscopic appendectomy has been performed in a total of 20 cases (12 with MM and 8 with SIT), of which two have undergone cholecystectomy at the same surgical session [3] [65]. Laparoscopy may be very useful both in establishing the differential diagnosis and in performing the definitive surgery [1].
As in patients with normally localized appendix, appendectomy specimens in LSAA should be sent for pathological evaluation. In the literature, only two of 95 patients (59 male, 76 female), who underwent appendectomy due to LSAA, were pathologically diagnosed with malignancy. Ascendent hemicolectomy was performed in both patients after pathological evaluation, which revealed mucinous adenocarcinoma and mucinous cystadenocarcinoma [19] [26]. In our case, the diagnosis was acute left sided appendicitis with no complications, no fluid collection, or abscess formation and successful endoscopic appendectomy was done, the caecum was located in left lower abdomen, the SIT was confirmed the surgery was videotaped and saved in hospital records, the pathological specimen showed signs of acute inflammation in the appendix. Ultrasonography before discharging the patient was unremarkable. The patient was doing well in his follow up visits.

Conclusion
LSAA should be considered in the differential diagnosis of young patients presenting with pain localized in the left lower quadrant. Chest X-ray, abdominal USG and CT provide very useful information. Endoscopic appendectomy in straight-forward cases and Diagnostic laparoscopy is the gold standard in cases with complicated differential diagnosis. Open Journal of Clinical Diagnostics

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The patient consented for images or clinical information relating to his case to be reported in a medical publication.

Conflicts of Interest
The author declares no competing interests in relation to their work.