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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Nelson MJ, Pesola GR. 2001. Left lower quadrant pain of

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Jacobson HG, Camp WH. 1951. Situs inversus of the abdomi-

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Wright CB, Morton CB. 1971. Situs inversus totalis with adeno-

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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