An unknown situs viscerum inversus totalis, accidentally discovered after a CT scan

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BACKGROUND

Situs viscerum inversus, also known as SIT, is a congenital anatomical disorder characterized by a mirror-image reversal of the major visceral organs, complete or not, with the organs arranged in a way opposed to the typical arrangement [1-4]. The term “situs” refers to the pattern of the viscera as well as to the individual asymmetric internal organ, which includes the gastrointestinal tract, liver, spleen, and lung [5].

The three types of SI are solitus or normal, inversus or the mirror image of normal, and situs ambiguous. So, situs solitus means normal anatomy, situs inversus describes total reversal, and situs ambiguous denotes any other anomaly of left-right development. The situs viscerum inversus could be divided into totalis or incompletes, also known as partial, and refers to a condition in which only some visceral organs are transposed while others remain in their normal place.

The extent of organ reversal varies; usually, the patient has a normal left-side heart and abdominal organ transposition [6-7]. 

The origin of those conditions is still unknown but is frequently asymptomatic, especially in the infant. This clinical condition could create several thoracic problems, especially in the level of the heart, and abdominal complications [8]. SIT could also complicate the diagnostic assessment and future treatment.

 

DESCRIPTION OF THE CASE

 

Anamnesis:

The patient, a 56-year-old female, came to the Emergency Department with recurrent and colic left flank pain, especially on the left; the patient referred an intermittent pain migrating upwards, to the back, and to the region under the shoulder blade and left shoulder [7-9]. She also reports nausea and vomiting so, a CT with a contrast medium was performed (►Fig. 1).

The patient hasn’t ever had any other significant chest-cardiac or respiratory symptoms or some previous CT exams; so, the first CT image of the thorax shows the radiologist a condition of dextrocardia and create a new diagnostic hypothesis; further imaging studies on the rest of the thorax and abdomen confirmed the diagnosis of SIT (►Fig. 2-3).

 

Diagnostic assessment.

The CT confirms the SIT: an asymptomatic situs viscerum inversus totalis (►Fig. 4).

In addition, the images from the high abdomen show a left-sided gallbladder with some micro-calculi, that could explain the clinical condition of recurrent flank pain on the left [1-5]. For the most part, this discovery appeared to be completely innocuous for the patient’s health [6].

 

The differential diagnosis.

In this clinical case, the differential diagnosis was the crucial point, and the first problem was to know which are the causes of the acute flank pain on the left [7-8]. The patient has opposed anatomy, so the causes of this pain are different than the normal: biliary colic on the left [9].

 

Interventions.

The present case is not directly related to significant symptoms or acute problems due to SIT; instead, the interventions were focused on critical symptoms and the management and prevention of complications [10-12]. The treatment of biliary colic aims to reduce pain with painkillers and antispasmodics, to relieve symptoms (►Fig. 5).

 

 

Instead, the future treatment regimen and follow-up for the SIT are frequently interdisciplinary, comprising pulmonologists, cardiologists, and gastroenterologists. The management plan is adapted to the individual needs of each patient.

 

Follow-up and outcomes.

 

Regular follow-up and communication between physicians and patients are essential for optimizing care and maintaining the best possible quality of life, in the present and the future condition [13-15].

 

DISCUSSION

Situs inversus refers to a reversal positioning of the heart and major internal organs [1-4].

It is an uncommon congenital anomaly that manifests as a mirror-image transposition of both the abdominal and thoracic organs [5]. Dextrocardia (true mirror image) is commonly related to situs inversus, and the aorta is up-directed on the opposite side (►Fig. 6).

So, this condition could affect the chest, and in particular the heart and the large vessels: because each cardiac chamber is asymmetrical, situs also applies to the heart.

Also, the artery vessel’s anatomy in the chest and the abdomen is mirrored (►Fig. 7).

The SIT still has no clear and recognized cause today. Given the frequent relationship between aberrant situs and other unusual congenital abnormalities, an acquired etiology originating from an in-utero insult that disrupts the normal process of differentiation and orientation has been proposed [8].

This anatomic condition could complicate the diagnostic process and the diagnostic/treatment operations especially if invasive.  Because of their rarity, practicing doctors, such as gastroenterologists, radiologists, and surgeons, typically have little experience with these patients [12-15]. 

 

CONCLUSION

Many people are unaware that they have situs inversus because usually, it does not produce any symptoms that would necessitate therapy. However, follow-up is necessary because having a mirrored anatomy can make future diseases more difficult to diagnose.  

Regular evaluations and communication between doctors and their patients with SIT are critical for optimizing care and preserving the highest possible quality of life, against the resolution of future pathologies and syndromic complications.

 

 

Sobre autores

Manuela Montatore

Department of Clinical and Experimental Medicine, Foggia University School of Medicine, Viale L. Pinto 1, 71121 Foggia, Italy.

Email: manuela.montatore@unifg.it
ORCID ID: 0009-0002-1526-5047
Itália

Marina Balbino

Department of Clinical and Experimental Medicine, Foggia University School of Medicine, Viale L. Pinto 1, 71121 Foggia, Italy.

Email: marinabalbino93@gmail.com
Itália

Federica Masino

Department of Clinical and Experimental Medicine, Foggia University School of Medicine, Viale L. Pinto 1, 71121 Foggia, Italy.

Email: federicamasino@gmail.com

Ruggiero Tupputi

Radiology Unit, “Dimiccoli” Hospital, Viale Ippocrate 15, 70051, Barletta (BT), Italy.

Email: rutudott@gmail.com
Itália

Giuseppe Guglielmi

University of Foggia

Autor responsável pela correspondência
Email: giuseppe.guglielmi@unifg.it
ORCID ID: 0000-0002-4325-8330

Medical Doctor, Full Professor of Radiology.

Department of Clinical and Experimental Medicine.

Itália

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