Situs inversus (also called situs transverse) is a rare congenital condition in which the major visceral organs are reversed, or mirrored, from their normal position. The incidence of this condition in the population is less than 1 in 10,000 people. Situs is a Latin term that means "position." The term situs inversus is a short form for the Latin phrase "situs inversus viscerum," meaning "inverted position of the internal organs" (Situs inversus, 2007).

There can be many degrees or forms of this rare condition. The anomalies can range from only one organ being inversed to situs inversus totalis in which all of the organs are positioned opposite their normal position. The case that is described in this article involves a gentleman with situs inversus totalis who was diagnosed on a routine esophagogastroduodenoscopy (EGD). According to Hernanz-Schulman (2005), the stomach may be located on the right, on the left, or in the midline. Gastric volvulus may occur because of faulty mesenteric attachments of the stomach. Malrotation anomalies encompass a wide spectrum that ranges from nonrotation to reversed rotation and faulty peritoneal attachments. The author further noted that duodenal atresia or stenosis may also be present.

Case Study

This article describes the case study of a 65-year-old gentleman who reported to the endoscopy suite for an EGD. The indications for the procedure were gastric reflux and dysphasia. The patient was prepared in the normal manner for the procedure and informed consent was obtained. Moderate sedation was initiated, and the procedure began. The esophagus was intubated successfully, but the physician had problems entering the stomach with the normal maneuvers. After a prolonged period and numerous attempts, the stomach was intubated and there was a look of surprise and excitement on the physician's face. He announced, "Situs inversus!!" The procedure was completed without any other difficulties. The physician stated that he basically had to reverse his normal movements to complete the examination. The final EGD report indicated "esophagus normal, stomach normal, duodenal bulb normal. The patient has situs inversus where the stomach is 180[infinity] inverted." Routine discharge instructions were given for postprocedure upper endoscopy, and the patient was discharged from the recovery room.

After careful review of the electronic record, there was one notation indicating that this patient had situs inversus on a physical examination done 2 years previously. It stated "lungs clear (situs inversus)." On the referral request from the primary care physician, however, there was no indication that this patient had this rare condition. The diagnosis, situs inversus, should be indicated on every referral for these patients. For a patient with situs inversus, something as simple as an electrocardiogram (ECG) can be difficult. Everything is reversed in these patients, therefore all of the leads for the ECG need to be flopped or reversed to get an accurate reading. When defibrillating someone with his or her heart in the reverse position, "the pads should be placed in reverse position. That is, instead of upper right and lower left, pads should be placed upper left and lower right "(Situs inversus, 2007).

Situs inversus also requires reorganization in regard to surgical procedures. In laparoscopic procedures such as cholecystectomy, situs inversus is not a contraindication (Prabhakar & Samplay, 2006), but it certainly has implications for the success of the procedure. Koo (2006) noted that laparoscopic procedures for these patients can result in technical difficulties and longer operative times because of the challenges associated with accommodating the patient's physiological abnormalities. Koo (2006) reported that recommendations for accommodating these challenges include rearranging port sites in a mirror image and standing on the opposite side of the patient.

Conclusion

Situs inversus is a rare condition. Once it is diagnosed, it is important to make notation of it on every referral request. A normal EGD, upon insertion of the endoscope into the mouth, takes less than 5 minutes in the hands of an experienced physician. As a result of this information not being available for the patient described in this case study, there were technical difficulties and a longer procedure time for the patient. The major risk factor of an EGD is perforation. In less-experienced hands, the results could have been perforation or an inability to complete the procedure because of being unaware of the reverse maneuvers needed to complete the task.

References