[Right-sided acute appendicitis in situs inversus totalis. Case report]. / Apendicitis aguda del lado derecho en situs inversus totalis. Reporte de caso.

Background: Acute appendicitis is widely recognized as the prevailing abdominal surgical emergency globally, exhibiting an annual incidence ranging from 96.5 to 100 cases per 100,000 adults. Conversely, situs inversus totalis is a rare anatomical anomaly characterized by the complete reversal of the chest and abdominal organs, occurring in approximately 1 out of every 10,000 to 50,000 individuals. Clinical case: 53-year-old female patient who presented to the emergency department with a complaint of diffuse abdominal pain of colic nature that had persisted for 5 days. The patient referred systemic hypertension, pre-diabetes mellitus type 2, and situs inversus as relevant medical history. A laparotomy procedure was conducted, revealing a perforated appendix located in the right hypochondrium. Additionally, the patient exhibited situs inversus totalis, with the colon positioned in its normal anatomical location. Conclusions: Due to the low incidence of situs inversus totalis, in cases similar to the one presented, the utilization of image studies and laboratory studies is imperative for accurate diagnosis. In the face of diagnostic suspicions and inconclusive paraclinical studies, the most effective approach is to pursue surgical examination and intervention, preferably utilizing laparoscopic techniques.

Introducción: la apendicitis aguda es la urgencia quirúrgica abdominal más frecuente en el mundo, con una incidencia anual de 96.5 a 100 casos por 100,000 adultos. Por otra parte, el situs inversus totalis es un trastorno posicional inverso de los órganos torácicos y abdominales con una incidencia de 1 en 10,000 a 50,000 personas. Caso clínico: paciente del sexo femenino de 53 años que se presentó en sala de urgencias refiriendo dolor abdominal difuso tipo cólico de 5 días de evolución. La paciente refirió hipertensión arterial sistémica esencial, prediabetes mellitus tipo 2 y situs inversus. Se realizó intervención quirúrgica (laparotomía) en la que se encontró el apéndice perforado en hipocondrio derecho y situs inversus totalis con colon en posición anatómica normal. Conclusiones: debido a la baja incidencia del situs inversus totalis, el diagnóstico en casos como el presentado representa un reto en el que el uso de estudios de imagen y laboratorio resulta indispensable. Ante la sospecha diagnóstica y estudios paraclínicos con resultados no concluyentes, la mejor estrategia consiste en la exploración y el manejo quirúrgicos, preferentemente laparoscópicos.

[Laparoscopic cholecystectomy with common bile duct exploration in situs inversus totalis patient]. / Colecistectomía con exploración de vías biliares laparoscópica en paciente con situs inversus totalis.

We present the case of a 77-year-old male patient with a diagnosis of chronic calculous cholecystitis and choledocholithiasis, with a history of situs inversus totalis. Therefore, a laparoscopic cholecystectomy with common bile duct exploration were performed, using the "french mirror technique", with stone extraction. Patient evolved favorably. The aim of this study is to present this clinical case that is rarely reported in the world literature (only 9 cases). Its importance lies in the fact that it would be the first published clinical case report of a laparoscopic cholecystectomy and bile duct exploration with removal of the common bile duct stones in a patient with situs inversus totalis, performed in Peru.

Situs inversus totalis asociado a síndrome de preexcitación ventricular: reporte de un caso / Situs inversus totalis and pre excitation syndrome

Resumen: El situs inversus totalis es la inversión congénita completa de órganos torácicos y abdominales. Se presenta el caso de una paciente de 3 años sin antecedentes médicos previos, a quien en atención primaria, y por un cuadro respiratorio agudo, se evidencia el hallazgo de dextrocardia y burbuja gástrica a derecha en la radiografía de tórax, sospechándose situs inversus totalis. Fue derivada a cardiología infantil donde se confirmó el diagnóstico con un ecocardiograma transtorácico, asociado a un hallazgo de preexcitación ventricular en el electrocardiograma. Una vez resuelto el cuadro respiratorio agudo, la paciente se mantiene controlada de manera periódica en atención primaria y por especialista de manera semestral.

Abstract: Situs inversus totalis is the complete congenital inversion of thoracic and abdominal organs. We present the case of a 3-year-old girl with no previous medical history. When seen with an acute respiratory syndrome, dextrocardia and gastric bubble on the right side led to the diagnosis of Situs inversus. She was referred to infant cardiology where the diagnosis was confirmed with a transthoracic echocardiogram. In addition, the electrocardiogram identified the presence of ventricular preexitation. Once the acute respiratory symptoms subsided, the patient remains controlled periodically in primary care and by a specialist every six months. No episodes of tachycardia have been detected.

Dextrocardia como hallazgo incidental: revisión a partir de un caso / Dextrocardia as incidental finding: review from a case

INTRODUCTION: Dextrocardia is characterized by the positioning of the heart to the right of the thoracic cavity, usually with the apex oriented to the right and its inverse anatomy 1,2. It is a rare congenital pathology that can be associated with other congenital cardiac anomalies, as well as a change in position of all thoracoabdominal structures 1-4. Its diagnosis in adult life is usually incidental. We present the clinical case of a 64-year-old man with an electrocardiogram that showed deviation of the QRS complex axis to the extreme right and a physical examination compatible with dextrocardia, which was later confirmed with images. OBJECTIVES: To review the medical literature related to the diagnosis of dextrocardia through the presentation of a clinical case. METHODS: The clinical data of the case were collected by means of anamnesis, physical examination and specialized exams of the patient, as well as his clinical file. The literary review was made using the MEDLINE® search engine for scientific journals. RESULTS: Dextrocardia affects less than 1% of the general population according to the studies reviewed. Its importance lies in the association with other congenital pathologies such as cardiac and extracardiac structural malformations, which increases morbidity and mortality in this group of patients. It is imperative, when suspected, complete the study with images that allow confirming or ruling out other structural anomalies.

Percutaneous closure of ostium secundum atrial septal defect using left internal jugular vein access in a child with situs inversus and absence of inferior caval vein.

Femoral vein access is the first choice for percutaneous atrial septal defect closure, and when it cannot be used due to anatomic reasons, the alternative sites should be considered, frequently increasing the complexity of the procedure. Here we report the case of a 3-year-old boy, with situs inversus and dextrocardia, electively referred for percutaneous closure of an ostium secundum atrial septal defect. During the procedure, agenesis of the infra-hepatic segment of the inferior caval vein was diagnosed, and no double inferior caval vein or right superior caval vein were identified by ultrasound or angiography. Therefore, we opted to perform the procedure through the left internal jugular vein, with fluoroscopy and transesophageal echocardiographic guidance. Catheters were navigated through a hydrophilic guidewire, and a Stiff guidewire was positioned in the left ventricle for better support. An Amplatzer septa occluder 19 was successfully deployed without major difficulties and the patient was discharged after 24 hours in good clinical condition. Percutaneous atrial septal defect closure through alternative access sites, especially in the presence of situs inversus, may pose significant challenges to the interventional team. In this case, the left internal jugular vein has shown to be a feasible option, allowing the navigation and manipulation of devices without complications. Provided the expertise of the interventional team, and awareness of the risks involved, alternative access sites can be successfully used for paediatric structural interventions.

[Situs inversus totalis: a case report]. / Situs inversus totalis: reporte de un caso.

The situs inversus totalis is a rare condition associated with multiple congenital malformations, the most common heart defects and is associated with more complex syndromes such as Kartagener. Most of the time, the defect is found after a physical examination for other reason. We reported the case of a patient diagnosed on the first day of extra-uterine life. It has been the first case reported in the state of Guerrero, with several prenatal history of interest. Our aim is to emphasize that early diagnosis completely changes the future healthcare. Reviewing the literature, it does not have any algorithm on searching protocol of congenital malformations and management attention on common pathologies.

El situs inversus totalis es una entidad rara asociada con múltiples malformaciones congénitas, las más frecuentes son las cardiacas; asimismo, se asocia a síndromes más complejos como el de Kartagener. En la mayoría de las ocasiones, la entidad es un hallazgo tras un examen físico por alguna otra razón. Presentamos el caso clínico de un paciente diagnosticado en el primer día de vida extrauterina; siendo este el primer caso reportado en el estado de Guerrero, con numerosos antecedentes prenatales de interés. Nuestro objetivo es enfatizar que el diagnóstico temprano modifica por completo la atención médica futura. Al revisar la literatura no se cuenta con algoritmo alguno sobre el protocolo de búsqueda de malformaciones congénitas, así como sobre el manejo de atención en patologías comunes.

Situs inversus totalis: a propósito de 2 casos clínicos / Situs inversus totalis: 2 case reports

Introducción: El situs inversus totalis es un hallazgo poco común. Sólo un pequeño porcentaje presentará cardiopatías asociadas, por lo que el diagnóstico suele realizarse de forma casual. Objetivo: Destacar las claves diagnósticas del situs inversus totalis y la importancia de un diagnóstico temprano. Caso clínico: Presentamos dos pacientes pediátricos de 9 y 14 años que fueron diagnosticados de forma incidental. El primer caso fue estudiado por dolor precordial, en la auscultación cardíaca se escuchaba aumento de ruidos cardíacos en precordio derecho y atenuados en el izquierdo. El electrocardiograma (ECG) mostró eje QRS y onda P de +150°, QRS estrecho de voltaje atenuado en precordiales V3-V6 y ondas T negativas en V1-V4 y aVL. La radiografía de tórax confirmó dextrocardia, además se apreció burbuja gástrica a la derecha y sombra hepática a la izquierda. La ecocardiografía evidenció dextrocardia especular clásica sin malformaciones asociadas. En el segundo caso se encontró incidentalmente dextrocardia en radiografía solicitada para evaluación de escoliosis. El ECG objetivó eje QRS +120°, eje onda P +150°, QRS estrecho de voltaje atenuado en precordiales izquierdas. La ecocardiografía doppler confirmó dextrocardia especular sin anomalías asociadas. En ecografía abdominal el hígado se encontró en hipocondrio izquierdo y el bazo en hipocondrio derecho. Conclusión: El diagnóstico temprano del situs inversus totalis es importante, dado que el abordaje quirúrgico torácico y abdominal es diferente y determinadas patologías pueden presentarse con clínica inusual. Además, tras el diagnóstico de situs inversus se puede estudiar la presencia de patologías asociadas como discinesia ciliar primaria (Síndrome de Kartagener).

Introduction: Situs inversus totalis is a rare find and only a small percentage are associated with heart disease; its diagnosis is usually made incidentally. Objective: To discuss the diagnostic features of situs inversus totalis and the importance of early diagnosis. Case reports: Two pediatric patients aged 9 and 14 years who were incidentally diagnosed are reported. The first case presented chest pain and during cardiac auscultation, increased heart sounds were heard on the right precordium and attenuated on the left. An electrocardiogram (ECG) showed P wave and QRS axis equal to +150°, narrow QRS voltage attenuated in V3-V6 precordial leads, and negative T waves in leads V1-V4 and aVL. Chest radiography confirmed dextrocardia, and gastric bubble was on the right and hepatic shadow on the left. Echocardiography showed classic mirror dextrocardia without associated malformations. In the second case, dextrocardia was found incidentally after radiography was requested for the evaluation of scoliosis. ECG showed QRS of +120°, P wave axis of +150° and narrow QRS voltage axis attenuated on left precordial leads. Doppler echocardiography confirmed dextrocardia without associated anomalies. Abdominal ultrasound found the liver in left upper quadrant and the spleen in right upper quadrant. Conclusions: Early diagnosis of situs inversus totalis is important because the thoracic and abdominal surgical approach is different and certain diseases could be presented with unusual characteristics. Also, after the diagnosis of situs inversus, the presence of associated pathologies such as primary ciliary dyskinesia can be studied (Kartagener syndrome).

Left-sided appendicitis: diagnosis and minimally invasive treatment.

Intestinal malrotation and situs inversus can have important repercussions if acute abdominal pain develops. Intraabdominal structures can have inverted position and thus may easily mislead the surgeon during physical examination. Fortunately, radiological exams have improved the preoperative diagnosis of these patients. However, in difficult cases when an underlying surgical disease is suspected, laparoscopy remains the gold standard in order to diagnose and treat if possible the suspected disorder. We present a case of acute left-side appendicitis in a child with unknown congenital intestinal malrotation. In addition, this case stressed the value of laparoscopy in daily practice to evaluate patients with atypical abdominal pain.

[Situs inversus totalis - 2 case reports]. / Situs inversus totalis. A propósito de 2 casos clínicos.

INTRODUCTION: Situs inversus totalis is a rare find and only a small percentage are associated with heart disease; its diagnosis is usually made incidentally. OBJECTIVE: To discuss the diagnostic features of situs inversus totalis and the importance of early diagnosis. CASE REPORTS: Two pediatric patients aged 9 and 14 years who were incidentally diagnosed are reported. The first case presented chest pain and during cardiac auscultation, increased heart sounds were heard on the right precordium and attenuated on the left. An electrocardiogram (ECG) showed P wave and QRS axis equal to +150°, narrow QRS voltage attenuated in V3-V6 precordial leads, and negative T waves in leads V1-V4 and aVL. Chest radiography confirmed dextrocardia, and gastric bubble was on the right and hepatic shadow on the left. Echocardiography showed classic mirror dextrocardia without associated malformations. In the second case, dextrocardia was found incidentally after radiography was requested for the evaluation of scoliosis. ECG showed QRS of +120°, P wave axis of +150° and narrow QRS voltage axis attenuated on left precordial leads. Doppler echocardiography confirmed dextrocardia without associated anomalies. Abdominal ultrasound found the liver in left upper quadrant and the spleen in right upper quadrant. CONCLUSIONS: Early diagnosis of situs inversus totalis is important because the thoracic and abdominal surgical approach is different and certain diseases could be presented with unusual characteristics. Also, after the diagnosis of situs inversus, the presence of associated pathologies such as primary ciliary dyskinesia can be studied (Kartagener syndrome).

Left-sided appendicitis: diagnosis and minimally invasive treatment. / Left-sided appendicitis: diagnosis and minimally invasive treatment.

Intestinal malrotation and situs inversus can have important repercussions if acute abdominal pain develops. Intraabdominal structures can have inverted position and thus may easily mislead the surgeon during physical examination. Fortunately, radiological exams have improved the preoperative diagnosis of these patients. However, in difficult cases when an underlying surgical disease is suspected, laparoscopy remains the gold standard in order to diagnose and treat if possible the suspected disorder. We present a case of acute left-side appendicitis in a child with unknown congenital intestinal malrotation. In addition, this case stressed the value of laparoscopy in daily practice to evaluate patients with atypical abdominal pain.

Left-sided appendicitis: diagnosis and minimally invasive treatment / Left-sided appendicitis: diagnosis and minimally invasive treatment.

Intestinal malrotation and situs inversus can have important repercussions if acute abdominal pain develops. Intraabdominal structures can have inverted position and thus may easily mislead the surgeon during physical examination. Fortunately, radiological exams have improved the preoperative diagnosis of these patients. However, in difficult cases when an underlying surgical disease is suspected, laparoscopy remains the gold standard in order to diagnose and treat if possible the suspected disorder. We present a case of acute left-side appendicitis in a child with unknown congenital intestinal malrotation. In addition, this case stressed the value of laparoscopy in daily practice to evaluate patients with atypical abdominal pain.

[Situs inversus totalis]. / Situs inversus totalis.

Situs inversus totalis (SIT) is a rare disease in which there is transposition of thoracic and abdominal organs. The symptoms of appendicitis in SIT are often confused with other intraperitoneal processes such as diverticulitis. We report the case of a 65-year-old, attended by emergency epigastric pain of 20 hours of the onset after a few hours left iliac fosse migrates associated with hyporexia. Diverticulitis is diagnosed in the first instance, and after the respective imaging tests is discarded for being relevant findings with situs inversus totalis and left poses appendicitis. Therefore, the realization of an adequate medical history and physical examination supported by imaging tests are important to keep in mind, appendicitis as part of the differential diagnosis, in order to avoid errors in diagnosis and treatment.

Colecistitis aguda en paciente con situs inversus totalis / Acute cholecystitis in a patient with situs inversus totalis

El objetivo del presente reporte es dar a conocer un caso de situs inversus y colecistitis aguda diagnosticado y tratado en el Hospital Al Wahda Mabar Thamar de Yemen. Paciente de sexo femenino, de 50 años, con dolor en epigastrio después de la ingestión de alimentos grasos. Dos días antes de su ingreso incrementa su intensidad y se mantiene en hipocondrio izquierdo, y además, presenta vómitos. Utilizando antibioticoterapia perioperatoria, se realiza incisión subcostal izquierda, y se encuentra colecistitis aguda con dilatación moderada del colédoco. Se realiza colecistectomía y coledocotomía, con buena evolución posoperatoria(AU)

The objective of present paper is to present a case of situs inversus and cholecystitis diagnosed and treated in the Al Wahda Mabar Thamar Hospital of Yemen. A female patient aged 50 with epigastric pain after ingestion of fatty foods; two days before its admission increase its intensity and remains in left hypochondrium and also vomiting. With the use of perioperative antibiotic-therapy, a left subcostal incision is made detecting an acute cholecystitis with a choledochal slight dilatation. A cholecystectomy and choledochotomy with a good postoperative evolution were performed(AU)

[Laparoscopic cholecystectomy in a patient with situs inversus totalis]. / Colecistectomía laparoscópica en una paciente con situs inversus totalis.

OBJECTIVE: To report a case with situs inversus totalis (SIT) and chronic cholelithiasis solved by laparoscopic surgery, outlining the utility of minimal invasive surgery and specific considerations in patients with anatomic variations. CASE REPORT: A case of a 46 year-old female who presented with a six-month history of abdominal colic pain at the left hypochondrium, accompanied with nausea and vomiting, is presented. On examination she had epigastric tenderness. Blood tests, including liver function tests, were normal. Electrocardiogram showed right axis deviation and right ventricular hypertrophy, in keeping with dextrocardia. Chest-X-Ray confirmed the diagnosis of dextrocardia. An ultrasound scan of the upper abdomen identified the gallbladder containing stones in the left upper quadrant. A CT scan visualized the spleen and the gastric camera in the right upper quadrant. Barium gastrointestinal transit, barium enema and abdominal-X-Ray were used as complementary diagnostic studies. A magnetic resonance cholangiography was not performed because the patient suffered from claustrophobia. Cholecystectomy and transcystic cholangiography were performed by laparoscopic route, taking care to set-up the operating theatre in the mirror image of the normal set-up for cholecystectomy. The patient completed a successful procedure without complications and was discharged 48 hours after the procedure. Histological exam diagnosed a chronic lithiasic cholecystitis. CONCLUSIONS: Laparoscopic cholecystectomy is an adequate surgical procedure for patients with total situs inversus and cholelithiasis, having a high security range. Detailed clinical examination is important for the diagnosis of previously unknown anatomic variations. Transcystic cholangiography is mandatory when a magnetic resonance cholangiography can not be performed. Furthermore, perhaps in this situation a left-handed surgeon is better prepared than a right-handed one to comfortably carry out the procedure.

Situs inversus totalis: presentación de un caso / Situs inversus totalis: a case report

Se trata de una paciente MCG, de 51 años de edad, que acude a consulta de su médico de familia por un chequeo rutinario, donde se le practica electrocardiograma y se interconsulta en Centro de Medicina Interna en el Policlínico Universitario Elena Fernández Castro del municipio Los Palacios, diagnosticándose por primera vez en la paciente un situs inversus totalis. Para su diagnóstico se utilizó el método clínico y los estudios imagenológicos. El diagnóstico de situs inversus pasa inadvertido en la mayor parte de los casos, llegando al diagnóstico incidentalmente durante el transoperatorio o como hallazgo imagenológico; por lo tanto, es necesario realizar una historia clínica adecuada con una minuciosa exploración física ante la sospecha del diagnóstico y posteriormente corroborarlo por medio de imaginología (radiografía de tórax, ultrasonografía y tomografía axial computarizada), con el fin de que el paciente conozca su padecimiento y pueda transmitirlo al personal de salud que lo atiende...(AU)

A 51 years old patient (MCG) attends to the family doctors office for a routine check-up. An electrocardiogram is indicated and is transferred to an Internal Medicine Center at Elena Fernandez de Castro University Outpatient Clinic, Los Palacios municipality. The patient was diagnosed for first time with situs inversus totalis. To diagnose this entity clinical methods and imaging studies were used. Situs inversus goes unnoticed in the majority of the cases. The diagnosis is incidentally carried out during the transoperative period or as imaging findings, that is why, it is necessary to write an adequate clinical history with a detailed physical examination when suspecting, corroborating it later by means of imaging procedures (thoracic x-ray, ultrasound and computerized axial tomography), making the patient knows the disorder as well as informing it to the health personnel that assist the patient...(AU)