Case Report

Acute left-sided appendicitis with situs inversus totalis: a case report

Abstract

Appendicitis is the most common cause of surgery in acute abdominal pain with a ratio of approximately 7%. Situs inversus totalis is a Rare condition in which orientation of all asymmetric organs is a mirror image of the normal one. A 24-year-old girl was referred into the emergency department with the acute left lower quadrant pain as chief complaint. Nausea and Loss of appetite were also reported. Pain was persistent with no radiation. Left lower quadrant tenderness was obviously observed in physical examination. Throughout her routine chest x-ray, dextrocardia was discovered. Abdominal ultrasonography showed situs inversus totalis with inflamed appendix. Appendectomy was performed, and the patient was discharged after 5-day hospitalization with no complica- tions anymore. Considering this, rare anomaly in acute abdomen in particular leads to early diagnosis and reduces complications such as perforation, abscess, and peritonitis as well as reduces hospitalization time.

Appendicitis is the most common cause of acute abdomen in emergency departments (ED) [1] and in patients with a mean age of between 10 and 30 years [2]. It causes up to 5% of referring to EDs [3].The lifetime rate of appendectomy is higher in women (25%) compared with men (12%). Initial misdiagnosed of appendicitis will be leading to abscess formation and perforation [4]. The mortality rate in nonPerforated appendicitis is reported to be less than 1%, but it can be increased up to 5% in delayed diagnosed appendicitis, particularly in young and older patients and in perforated appendicitis [1].

Situs inversus totalis is a rare condition in which orientation of all asymmetric organs is a mirror image of the normal one (situs solitus) [5-7]. Incidence of situs inversus varies from 1:4000 to 1:20 000 [8] and commonly occurs with dextro- chardia [9], and rarely with levocardia [10].

Situs inversus with dextrocardia is usually be discovered by routine chest x-ray or physical examination [11].

A 24-year-old girl was brought to the ED (Emam Hospital, Ilam-Iran, September 2007) with abdominal pain.

Her pain started 6 hours before coming to ED and localized on left lower quadrant (LLQ) without radiation. She also complained of nausea, fever, and loss of appetite. Neither vomiting nor dysuria was observed. Pain was not altered with various positions and continued with no break. Considering her medical history, she had no any significant disease except left ear hearing loss due to Otitis media last year. Her father had cardiovascular disease. In terms of lifestyle, she was not a smoker and never consumed alcoholic drinks or any drugs or medicines in regular bases. The patient looked agitate and anxious. Blood pressure was 110/85 mm Hg, pulse rate was 90 beats/min, and respiratory rate was 17/min, but temperature (oral) was

38.5?C. Physical examinations revealed hypoactive bowel sound and LLQ tenderness without rebound tenderness. No mass was detected on Abdominal examination. She had no any costovertebral angel tenderness on both sides. white blood cells was 12 900/mm³ with shift to left (band forms = 12%), but amylase, lipase, and liver function tests were normal (Table 1). Kidneys, ureters, and bladder radiography was normal. Electrocardiography showed a right axis heart. A plain chest x-ray showed dextrocardia (Fig. 1). The second abdominal examination was performed after 30 minutes and revealed LLQ tenderness once again. Pain was persistent with no reduction. Using Alvarado scores [12], she got 5 score. Based on observed signs, symptoms and dextrocardia, as well as considering history of hearing loss, we suspected to situs inversus totlais and acute left-sided appendicitis.

An Abdominal ultrasound examination was undertaken. It revealed inflamed appendicitis with 9-mm diameter in LLQ. Her liver was located in left upper quadrant and her spleen in right upper quadrant. After situs inversus was definitely confirmed, the patient was prepared for laparatomy. Fluid therapy was started in ED, and she was prepared for surgery. On the laparatomy, 3 Ladd bands were seen throughout Small intestine and were released. A swollen appendicitis was removed, and the patient was discharged after 5 days with no complications. Considering her biopsy in clinical pathology department, a gangrenous appendicitis was diagnosed.

Although appendicitis is the most frequent cause of surgery in acute abdominal pain [1] and it is still between 5 top causes of litigation against emergency physicians [13], a highly suspicious is required in every condition.

0735-6757/$ - see front matter (C) 2010

1058.e6 Case Report

Table 1 complete blood count , WBC differentiation, Urine analysis, liver function tests, and Pancreatic enzymes

Complete blood count

WBC RBC

Hemoglubin Hematocrit MCV

MCH MCHC

Platelet

WBC differentiation segmented neutrophils Band forms

Basophils Eosinophils Lymphocytes Monocytes Urine analysis Appearance Specific gravity pH

Protein Glucose Ketones Bilirubin Occult blood Nitrite

WBC RBC

Renal epithelial cells Squamous epithelial cells Casts

Bacteria Yeast SGOT SGPT

Alkaline phosphatase Amylase

Lipase

129 000/mm³

4.8 x 10⁶

12 g/dL

44%

86

28

32%

212 000

60%

12%

0.5%

1.5%

23%

3%

Clear, yellow 1.003

5.2

Negative Negative Negative Negative Negative Negative

4/high-power field 3/high-power field 3/high-power field None/high-power field None

None None 20 IU/L

22 IU/L

78 U/L

80 U/L

53 U/L

WBC indicates white blood cells; RBC, red blood cells; MCV, mean corpuscular volume; MCH, mean corpuscular hemoglobin; MCHC, mean corpuscular hemoglobin concentration; SGOT, serum glutamic- oxaloacetic transaminase; SGPT, serum glutamic-pyruvic transaminase.

Fig. 1 A posteroanterior chest x-ray shows dextrocardia. Trachea

(T) slightly shifts to the left. Aortic arc (AA) is located in the right side. Heart apex (A) is located in the right side. Stomach bubble (S) is visible in the right side of abdomen.

the situs inversus has not been previously discovered. Although right lower quadrant tenderness is important and has 2 points in Alvarado scores [12], we show that the absence of right lower quadrant tenderness in physical examination could not rule out appendicitis. The present case report shows the significance of local tenderness in appendicitis. Before any procedure, improper image labeled should be rechecked [7] for possible mistakes. Considering this, rare anomaly in acute abdomen in particular leads to early diagnosis and reduces complications such as perfo- ration, abscess, and peritonitis and also reduces hospital- ization time.

According to the vermiform position of the appendix: retrocaecal and retrocolic, pelvic, ileal type, subcecal, and paracolic and midinguinal (very rare) [14], symptoms may vary, and we found various signs in physical examination.

Situs inversus is a rare condition that associated with multiple congenital defects [6] and higher incidence of vascular anomalies [5]. Patients with situs inversus usually have a normal Life expectancy, but when it occurs with cardiac anomalies, life expectancy will be decreased [15].

Various anomalies and mirror image of abdominal viscera in situs inversus and also various anatomy of appendix make the diagnosis of appendicitis very difficult, particularly when

Hamidreza Seifmanesh MD Kioumars Jamshidi MD Abdolrassoul Kordjamshidi MD Department of Surgery

Ilam University of Medical Science

Ilam, Iran

Ali Delpisheh Department of Clinical Epidemiology Ilam University of Medical Science

Ilam, Iran E-mail address: [email protected]

Hadi Peyman RN Masood Yasemi

Ilam University of Medical Science

Ilam, Iran

doi:10.1016/j.ajem.2010.01.020

Case Report

References

1. Liu C, McFadden D. Acute abdomen and appendix. In: Greenfield LJ, et al, editor. Surgery: scientific principles and practice, 2d ed, Vol. 1246-61. Philadelphia: Lippincott-Raven; 1997.
2. Korner H, et al. Incidence of acute nonperforated and perforated appendicitis: age-specific and sex-specific analysis. World J Surg 1997;21(3):313-7.
3. Kamin RA, et al. Pearls and pitfalls in the emergency department evaluation of abdominal pain. Emerg Med Clin North Am. 2003;21(1): 61-72, vi.
4. Graff L, et al. False-negative and false-positive errors in abdominal pain evaluation: failure to diagnose acute appendicitis and unnecessary surgery. Acad Emerg Med 2000;7(11):1244-55.
5. Kamitani S, et al. laparoscopic cholecystectomy in situs inversus totalis with “inferior” Cystic artery: a case report. World J Gastroenterol 2005;11(33):5232-4.
6. Marta MJ, et al. A case of complete situs inversus. Rev Port Cardiol 2003;22(1):91-104.
7. Sirin BH, Kurdal AT, Iskesen I. Congenitally corrected transposition of the great arteries plus dextrocardia operated with an unusual operative technique. Thorac Cardiovasc Surg 2008;56(6):367-9.

1058.e7

1. Demetriades H, et al. Laparoscopic cholecystectomy in two patients with symptomatic cholelithiasis and situs inversus totalis. Dig Surg 1999;16(6):519-21.
2. Maldjian PD, Saric M. Approach to dextrocardia in adults: review. AJR Am J Roentgenol 2007;188(6 Suppl):S39-S49 quiz S35-8.
3. Gindes L, et al. Isolated levocardia: prenatal diagnosis, clinical importance, and literature review. J Ultrasound Med 2007;26(3): 361-5.
4. Piryani RM, et al. Situs inversus with dextrocardia with multiple cardiac lesions in adult. Kathmandu University Med J 2007;5(2): 247-9.
5. Alvarado A. A practical score for the early diagnosis of acute appendicitis. Ann Emerg Med 1986;15(5):557-64.
6. Rusnak RA, Borer JM, Fastow JS. Misdiagnosis of acute appendicitis: common features discovered in cases after litigation. Am J Emerg Med 1994;12(4):397-402.
7. Wakeley CP. The position of the vermiform appendix as ascertained by an analysis of 10,000 cases. J Anat 1933;67(Pt 2): 277-83.
8. Bohun CM, et al. A population-based study of cardiac malformations and outcomes associated with dextrocardia. Am J Cardiol 2007;100 (2):305-9.