The presentation is about a patient who is having Situs Inversus Totalis and is also suffering from multiple gall bladder stones. Patient's physician have decided to undergo cholecystectomy. Sources are already mentioned in the presentation. Hope the presentation helps to gain some information.

1. STORY OF THE OPPOSITE
CASE PRESENTATION
SHRISTI BHASKAR
MEDS-19-4
To- Dr. Vakhtang R.

2. CASE
A 43-year-old woman, who was diagnosed
5 years ago to have dextrocardia by a chest
X-ray performed for an attack of pneumonia.
She presented to us with a 3-month history
of vague upper abdominal pain and flatulent
dyspepsia. The pain was mainly felt in the
epigastric region and was radiating to the
back, mainly felt after heavy meals. She had
no vomiting, fever, jaundice or weight loss.
She never had investigations for her
condition before. On examination the patient
did not have jaundice, abdominal
examination was negative apart from
tenderness at the epigastric and left upper
quadrant. To be mentioned, the apex beat
was felt on the right side of the chest.

3. Laboratory Investigations
➢ Laboratory investigations including liver
function tests were normal.
➢ Chest X-ray , ECG and echocardiography
confirmed the previous diagnosis of
dextrocardia.
➢ Ultrasonography demonstrated that the liver
was located mainly on the left side of the
abdomen and the spleen on the right.
➢ The gallbladder, filled with multiple
gallstones, located on the left side.
➢ The bile ducts were normal.
➢ Ultrasound and CT prescribed.
Chest X-ray of the patient
demonstrating dextrocardia.

4. Differential Diagnosis of Epigastic Pain
➔ Biliary: cholecystitis, cholelithiasis, cholangitis
➔ Cardiac: myocardial infarction, pericarditis
➔ Gastric: esophagitis, gastritis, peptic ulcer
➔ Pancreatic: mass, pancreatitis
As the pain was epigastric with tenderness on epigastric left region along with
gallstones and the prescribed test with the fact that the patient has pain after heavy meal
Biliary is the most favorable hypothesis.

5. Radiologic Findings
CT scan coronal section demonstrating
the liver located in the left side of the
abdomen.
CT scan axial section
demonstrating the liver located in
the left side of the abdomen.
Gallbladder ultrasound.

6. CT scan of the abdomen and chest confirmed
the diagnosis of Situs Inversus Totalis.
Situs inversus is not a risk factor for cholelithiasis by itself, but it carries a risk of diagnostic
confusion since the symptoms and signs will be misleading as they are arising from abnormally
positioned gallbladder especially in patients in whom the diagnosis of situs inversus have not
been made yet, and a delay in the diagnosis is expected.

7. Totalis
Reversal of organs, total: This condition
(medically called situs inversus totalis)
involves complete transposition (right
to left reversal) of the thoracic and
abdominal organs. The heart is not in
its usual position in the left chest, but is
on the right.Situs inversus is a rare
autosomal recessive disorder which
refers to a spectrum of mirror image
transpositions of the thoracic viscera,
abdominal viscera, or both, and is
present in approximately 1 in 5000–
20 000 live-births.

8. 0.0001%
Situs inversus is a very rare
condition. According to an
article in the journal Heart
Views , it occurs in an
estimated 1 in 10,000 people.

9. Medical Jargons
CHOLECYSTECTOMY
● A cholecystectomy is a surgical procedure for the
removal of the gallbladder. The gallbladder is a sac
attached to the digestive system that contains bile to
break down fats.
● A cholecystectomy is most commonly undertaken
because of Cholecystitis, an inflammation of the
gallbladder wall. Gallstones usually cause this
inflammation by blocking the flow of bile from the
gallbladder to the liver.
Laparoscopic Cholecystectomy
● A laparoscopic cholecystectomy is a surgery during
which the doctor removes your gallbladder. This
procedure uses several small cuts instead of one large
one. A laparoscope, a narrow tube with a camera, is
inserted through one incision. This allows your doctor
to see your gallbladder on a screen.

10. Treatment
➢ The patient was scheduled for elective
laparoscopic cholecystectomy.
➢ The situs inversus was confirmed, the stomach
and spleen were on the right side and the liver
and gallbladder were on the left side.
➢ After achieving a clear view of safety of the
triangle of Calot, the cystic duct and artery
were clipped and the gallbladder dissected
away from the liver bed and extracted safely.
➢ Laparoscopic cholecystectomy is much more
challenging in the presence of this disorder due
to loss of usual orientation.
➢ For controlling diarrhea after cholecystectomy
include: Anti-diarrheal medications, such as
loperamide (Imodium A-D) Medications that
impair absorption of bile acids, such as
cholestyramine.

11. Some visuals of the Cholecystectomy
A laparoscopic view showing the gallbladder in
the left side of the peritoneal cavity.
A laparoscopic view showing the stomach in
the right side of the peritoneal cavity.

12. References -
➢ https://www.ncbi.nlm.nih.gov/pmc/articles/PMC3822187/
➢ https://www.ipart.nsw.gov.au/files/sharedassets/website/trimhol
dingbay/report_-_case_study_4_-
_cholecystectomy_gall_bladder_surgery_-_july_2010_-
_hospital_review_2009
➢ https://www.hindawi.com/journals/cris/2015/845613/

13. Dhanyawaad!