Acute left-sided appendicitis with situs inversus totalis:
a case report
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)  and in patients with a
mean age of between 10 and 30 years . It causes up to 5%
of referring to EDs .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 . 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 .
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  and commonly occurs with dextro-
chardia , and rarely with levocardia .
Situs inversus with dextrocardia is usually be discovered
by routine chest x-ray or physical examination .
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 (WBC) was 12 900/mm
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 , 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  and it is still between 5
top causes of litigation against emergency physicians ,a
highly suspicious is required in every condition.
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American Journal of Emergency Medicine (2010) 28, 1058.e5–1058.e7