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CLINICAL CONUNDRUM
Left Sided Abdominal Pain in a Patient WithSitus Inversus
ALOK TIWARI,* SIMON MACMULL, STEVE FOX, AND SABU A. JACOB
Department of Surgery, King George Hospital, Goodmayes, Essex, United Kingdom
INTRODUCTION
In female patients with situs inversus, the most
common differential diagnosis of left iliac fossa pain
would include appendicitis, ovarian cyst, and ectopic
pregnancy. In this report, we describe a new cause
for left iliac fossa pain, Crohn’s disease.
CASE REPORT
A 30-year-old woman presented to the emergency
department, with an intermittent 9-week history of
crampy abdominal pain. Her symptoms had wors-
ened over the previous 4 days, with associated nau-
sea and vomiting and reduced appetite. Her bowels
were regular and there were no urological or gyneco-
logical symptoms. She had been treated by her gen-
eral practitioner for the abdominal pain, with panto-
prazole, buscopan, and alverin with no effect.
Her past medical history included situs inversus
that had been diagnosed during a maternity scan.
There was no significant family history of note.
On examination, she was pyrexial and had a mild
tachycardia. She had a soft abdomen but with tender-
ness and guarding in the lower abdomen, especially in
the left iliac fossa. Her white blood count was 19,000
and she had a negative pregnancy test. An ultrasound
performed by her general practitioner 1 week previ-
ously had shown a small ovarian cyst with some fluid
in the pouch of Douglas. An abdominal radiograph
(Fig. 1) showed dilated loops of small bowel with the
point of obstruction in the left iliac fossa.
A differential diagnosis of appendiceal pathology
causing small bowel obstruction or a ruptured ovar-
ian cyst was made and a repeat ultrasound was per-
formed. That ultrasound showed no ovarian pathol-
ogy rather an enlarged appendix surrounded by fluid
suggestive of acute appendicitis. She was taken to
the operating room for an appendectomy.
A left transverse Lanz incision was made and
muscle splitting was undertaken, as for a standard
appendectomy. On entering the peritoneum she was
noted to have small bowel obstruction with a moder-
ate amount of free intraperitoneal fluid. A loop of
bowel was stuck in the pelvis. There was a thick-
ened loop of distal ileum causing the bowel obstruc-
tion (Fig. 2). The appendix also looked thickened
but without any evidence of acute appendicitis.
Because of her symptoms and the findings of small
bowel obstruction, a limited right hemicolectomy
was performed using interrupted seromuscular suture
for the anastomosis using Polydioxanone. A standard
closure was performed. The patient had an unevent-
ful recovery and was discharged 6 days later.
Histology of the resected specimen showed scarred
and fibrosed serosa leading to an inflammatory and
fibrotic mass around the terminal ileum consistent with
longstanding inflammation. The cecum and ascending
colon was not involved. This was consistent with
Crohn’s disease. The appendix was reported as normal.
Since discharge she has been monitored by the sur-
gical team and was well, apart from occasional abdomi-
nal pain. She was subsequently started on Pentasa, 1
mg twice a day, with resolution of her symptoms. The
patient remains well 6 months after the operation.
DISCUSSION
Situs inversus is a rare condition with an incidence
of approximately 1 in 10,000 people. In this condition,
there is a mirror image location of the organs. This
can be total inversion (also known as situs inversus
totalis), inversion of various organs or inversion of indi-
*Correspondence to: Alok Tiwari, MS, MRCSEd, 7 Pearson
Close, New Barnet EN5 5NE, UK.
E-mail: atiwari8r@rcsed.ac.uk, aloksushma@tiwari.fsnet.co.uk
Received 11 January 2005; Revised 14 March 2005; Accepted 27
April 2005
Published online 28 October 2005 in Wiley InterScience (www.
interscience.wiley.com). DOI 10.1002/ca.20201
VVC 2005 Wiley-Liss, Inc.
Clinical Anatomy 19:154–155 (2006)
vidual organs, where it may be known as situs ambig-
uous (Raahave et al., 1980; Nelson et al., 2001). Some
patients may have associated dextrocardia or levocar-
dia. These patients may suffer from all the normal
intraabdominal conditions, including cholecystitis, pan-
creatitis, sigmoid and cecal volvulus, cecal tumor, and
acute appendicitis (Jacobson et al., 1951; Wright et al.,
1971; Raahave et al., 1980; Nelson et al., 2001; Ratani
et al., 2002). The incidence of left sided appendicitis
has been reported to be 0.04% (Nelson et al., 2001).
The diagnosis is, however, not easily recognized
because of the atypical presentations.
In this report, we have highlighted the first case of
Crohn’s disease as a cause of left iliac fossa pain. In our
patient, there was a prolonged history of abdominal pain
that had gradually worsened, which might have led us
to an alternative diagnosis rather than acute appendici-
tis. However, it is known that only about 60% of
patients with appendicitis present with typical symp-
toms. Patients (2–3%) operated for suspected appendi-
citis are found to have Crohn’s disease. The other path-
ology described thus far in the literature had not
included Crohn’s disease in patients with situs inversus,
and it was unlikely that the patient had a cecal tumor or
volvulus. The ultrasound in our case was suggestive of
appendicitis as macroscopically the appendix did look
thickened, and there was free fluid in the abdomen.
Computed tomography may have been helpful (Nelson
et al., 2001; Ratani et al., 2002). However, the abdomi-
nal radiograph showed features of small bowel obstruc-
tion, and thus, there was a need for surgical interven-
tion. Surgical treatment resulted in a good outcome.
Although rare, in patients with situs inversus and
left iliac fossa pain, the differential diagnosis should
now also include Crohn’s disease. If this is sus-
pected, in early cases medical treatment may suffice
although surgery will still be needed if there is
obstruction as in our case.
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Ratani RS, Haller JO, Wang WY, Yang DC. 2002. Role of
CT in left-sided acute appendicitis: Case report. Abdom
Imaging 27:18–19.Fig. 1. Abdominal radiograph demonstrating small bowel
obstruction in the area of the iliac fossa (arrowed).
Fig. 2. A: Resected specimen with the thickened loop of ileum
(thin arrow) and the appendix. Note the ileum joining the cecum
from a right medial position, and the appendix lying in a left lateral
position (thick arrow). B: Cut surface of the thickened ileum show-
ing features that led to the small bowel obstruction. [Color figure
can be viewed in the online issue, which is available at www.
interscience.wiley.com.]
155Left Sided Abdominal Pain in a Patient