All Switched Up: Abdominal Pain in a Patient With Situs Inversus Totalis

Abstract

Situs Inversus Totalis (SIT) is the rare condition in which the abdominal organs and organs in the thorax lie in position that is a mirror image from their usual orientation. This condition occurs in less than 0.0001% of live births. Many with SIT are unaware of the anomaly until incidentally found on imaging or ECG. We report a case of abdominal pain that we believe to be secondary to SIT. We find this case interesting because SIT is a rare condition that is usually asymptomatic. A 35-year-old man presented to GI clinic with abdominal pain that began 8 months prior. He described it as a burning discomfort that radiated from the epigastrium to his suprapubic region. It was intermittent and associated with bloating. He reported relief with marijuana use and aloe-vera lotion. He denied associated nausea/vomiting, dysphagia/odynophagia, hematochezia/melena, or weight loss. He reported being treated for H. Pylori infection in the past, no other medical history. No previous EGD/colonoscopy. No family history of GI malignancy. Reports marijuana use and occasional cocaine use. His vital signs were unremarkable. On exam, his abdomen was soft, non-distended and non-tender in all 4 quadrants. Review of the medical records revealed previous liver ultrasound reporting SIT. Labs were unremarkable including CMP, CBC, Stool H. Pylori Ag, Hepatitis C Ab. An abdominal CT is with contrast was ordered. He was started on an empiric trial of omeprazole for symptomatic relief, and followed up in 2 months with no relief. Labs were unremarkable and imaging was notable only for SIT. He reported continued symptoms at this follow-up visit. The patient was subsequently lost to follow-up and unavailable by phone. In patients with a family history or personal history of SIT, it is important to consider the implications this may have on their presenting symptoms. This awareness can aid in the timely diagnosis of common conditions such as appendicitis, diverticulitis and biliary colic where the physical exam findings would be on the opposite side. Intestinal ischemia in SIT patients related to intestinal malrotation or mestenteric hernias is reported in the literature. Special consideration should be taken for procedural approach if abdominal interventions are required. Anatomy should not impede this, as techniques and approaches have been reported for patients with SIT requiring laparoscopic cholecystectomy, percutaneous biliary stenting, therapeutic ERCP and even liver transplantation.Figure: CT scan imaging showing situs inversus, note liver on left and stomach on right side of patient's body.