Appendicular Peritonitis in Situs Inversus Totalis: A Case Report

Mamadou Cissé; Alpha O Touré; Ibrahima Konaté; Madieng Dieng; Ousmane Ka; Fodé B Touré; Abdarahmane Dia; Cheikh T Touré

Disclosures

J Med Case Reports 

In This Article

Discussion

Situs inversus is a positional anomaly that rotates the abdominal internal viscera. It is known as situs inversus totalis when it is associated with a transposition of the thoracic organs. Situs inversus is a rare congenital anomaly with an incidence in the population of only 0.001% to 0.01%[1,2] with a male-to-female ratio of 3:2.[3] Its transmission mode is autosomal recessive, but its precise genetic mechanism has yet to be identified.[1,3]

Situs inversus results from a rotation in the opposite direction of the viscera during the development of the embryo.[2,3] Patients with situs inversus may face diagnostic problems because of the unusual localizations of their symptoms. In the case of our patient's pain in the left iliac fossa, the differential diagnosis we made was extensive. Even in patients without situs inversus, the right iliac appendicular symptoms would be found in only 60% of cases.[1,3] The presence of symptoms in the left iliac fossa in the absence of situs inversus may be due to an abnormally long appendix projected to the left, or to intestinal hyperkinesis.

A study of 71,000 patients appendicular symptoms found that 0.04% of cases involved left iliac localization, comprising 0.024% with abdominal situs inversus and 0.016% with situs inversus totalis.[3,4] Until 2008, fewer than 10 cases of appendicitis associated with situs inversus were reported in the literature.[3] Half of these patients reported pain in their right iliac fossa despite the presence of situs inversus.[1] Therefore, given the scarcity of this association, the diagnosis of appendicitis with situs inversus is not automatically evoked, which delays the appropriate management of patients. As a consequence, as in the case of our patient, peritoneal diffusion may eventually develop.

Meanwhile, the usual differential diagnosis of left lower quadrant abdominal pain in an adult man includes, among others, sigmoid diverticulitis, epididymitis, bowel obstruction, psoas abscess, and, in this rare instance, situs inversus with acute appendicitis. Medical imaging can help clinicians to arrive at a correct diagnosis. Abdominal X-ray, ultrasonography, and tomodensitometry can also facilitate an accurate and early diagnosis if a patient is unaware of this positional anomaly.[1,3,4] Medical imaging can also guide the appropriate therapeutic choice, surgical indication, and type and location of the incision.[4] The contribution of laparoscopy is undeniably useful in these situations, as it favors a minimally invasive surgical approach in diagnostics and treatment.[5]

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