2158 Successful Endoscopic Retrograde Cholangiopancreatography in a Patient With Situs Inversus and Choledocholithiasis

Abstract

INTRODUCTION: Situs inversus is a congenital condition that causes left-right reversal of all organs. This results in unique challenges for the endoscopist when patients with situs inversus require ERCP. Several methods have been described in the literature to optimize the chances of successful cannulation in these unique patients. We describe the case of a 75 year old woman with situs inversus who developed choledocholithiasis requiring ERCP for stone extraction. We review the clinical features of situs inversus, as well as the methods needed to obtain successful cannulation. CASE DESCRIPTION/METHODS: A 75 year old woman with complete situs inversus was transferred to our facility. Eight days prior to this presentation, she developed epigastric pain and emesis. She had new liver test abnormalities with ALT 277, AST 110, alkaline phosphatase 221, and total bilirubin 5.5. A CT scan showed dilation of the common bile duct to 7 mm with a 6 mm stone noted in the distal duct. Upon arrival at our facility, ERCP was performed in the left lateral position. The procedure was notable for distortion of the stomach and duodenal bulb consistent with situs inversus. A precut sphincterotomy was necessary to achieve biliary cannulation. The bile duct was noted to come off the ampulla at 1 o’clock, in mirror image from normal anatomy. A 9 mm stone was identified and removed with a basket. DISCUSSION: Situs inversus is an autosomal recessive congenital condition with an incidence rate of approximately 1 in 5,000 to 10,000 live births. There is no evidence that situs inversus contributes to increased gallstone formation. Currently, there are 15 cases of ERCP performed for choledocholithiasis in situs inversus patients described in the literature. Besides the obvious differences in the orientation of the stomach and duodenum, the bile duct is often noted to come off the ampulla at “1 o’clock” instead of the typical “11 o’clock.” A variety of methods have been described to address these anatomical differences, including placing the patient in the prone position, changing the side of the bed that the endoscopist stands on, setting up the ERCP suite in mirror image, and rotating the duodenoscope 180 degrees clockwise in the stomach, and then either rotating an additional 180 degrees in the second portion of the duodenum or using a rotating sphincterotome. Endoscopists should be aware of the various techniques to optimize cannulation in patients with situs inversus to maximize chances of a successful intervention.