2770 A Unique Case of Bezoar and Incidental Situs Ambiguus

Abstract

INTRODUCTION: Situs ambiguous refers to abnormal arrangement of thoracoabdominal organs along left-right body axis, and is associated with multiple complex congenital cardiac as well as non-cardiac anomalies. This abnormal arrangement is different from orderly arrangement seen in situs solitus or situs inversus. We report a unique case of incidental situs ambiguous discovered during management of aspiration pneumonia caused by gastric outlet obstruction. CASE DESCRIPTION/METHODS: 62-year-old gentleman presented with one month history of multiple episodes of non-bilious vomiting and watery diarrhea, two weeks of abdominal distension and discomfort. Semi-urgent esophagogastroduodenoscopy (EGD) revealed partially digested food particles with inadequate views (bezoar). Placement of a nasogastric tube (NGT) triggered gag reflux resulting in vomiting and aspiration of gastric contents, causing hypoxia needing emergent intubation. Chest x-ray revealed bilateral infiltrates with loss of lung volume on the right. Urgent bronchoscopy revealed food particles predominantly in right bronchus intermedius. Patient developed acute respiratory distress and septic shock from aspiration pneumonia. CT abdomen showed a grossly enlarged stomach (gastric outlet obstruction) on the right side of the abdomen (situs ambiguous) with bezoar. EGD revealed voluminous amount of residue in markedly distended stomach; three liters were suctioned using a large bore Edlich gastric lavage tube. Benign appearing tight stenosis was noted in the duodenal bulb. Biopsies were negative for Helicobacter pylori or lymphoma. Although endoscopic dilation of stricture was initially considered, gastrojejunostomy was performed to bypass the stricture given severity of illness and prolonged recovery. DISCUSSION: Situs ambiguus is classified into two groups. Group I has isomerism of right atrial appendage and is usually associated with absence of spleen (Asplenia syndrome). Group II has isomerism of left atrial appendage and is usually associated with multiple spleens (Polysplenia syndrome). Liver is usually centrally placed or may remain in right or left hypochondrium. Mortality up to 40% at a very young age up was reported. Our patient remained asymptomatic due to absence of cardiac anomalies. Edlich tube is a large bore 36Fr NGT, 36” long, with a closed tip and multiple eyes, a 140cc syringe with a quick connect adapter on the tube. It is used to irrigate or lavage the stomach and plays an essential role in breakdown and evacuation of bezoars.