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Int J Surg Case Rep
Int J Surg Case Rep
International Journal of Surgery Case Reports
2210-2612
Elsevier

S2210-2612(24)01030-7
10.1016/j.ijscr.2024.110249
110249
Case Report
A case of amoebic liver abscess and emphysematous gallbladder in a 65-year-old male with situs inversus totalis
Issa Shadi a
Alsaffaf Yousef yousof.safaf@gmail.com
b⁎
Sheikh Sobeh Ahmed b
Hamsho Suaad c
Ali Moulham d
a General Surgery Department, Faculty of medicine, Damascus University, Damascus, Syria
b Faculty of Medicine, Hama University, Hama, Syria
c Rheumatology Department, Faculty of Medicine, Damascus University, Damascus, Syria
d Gastroenterology Department, Faculty of medicine, Damascus University, Damascus, Syria
⁎ Corresponding author at: Assi Square, Hama, Syria. yousof.safaf@gmail.com
08 9 2024
10 2024
08 9 2024
123 11024922 7 2024
28 8 2024
4 9 2024
© 2024 The Author(s)
2024
https://creativecommons.org/licenses/by-nc-nd/4.0/ This is an open access article under the CC BY-NC-ND license (http://creativecommons.org/licenses/by-nc-nd/4.0/).
Introduction and importance

Situs inversus totalis, a rare congenital condition, is characterized by the mirror-image reversal of the abdominal and thoracic organs. Amoebic liver abscess and emphysematous gallbladder are severe gastrointestinal infections. The coexistence of these three conditions is extremely rare.

Case presentation

We present the case of a 65-year-old male who presented with abdominal pain, fever, and jaundice. Investigations revealed situs inversus totalis, amoebic liver abscess, and emphysematous gallbladder. The patient underwent successful treatment with antibiotics and open surgery drainage of the liver abscess, and subtotal cholecystectomy.

Clinical discussion

The co-occurrence of situs inversus totalis, amoebic liver abscess, and emphysematous gallbladder poses a diagnostic challenge and requires thorough evaluation and appropriate management.

Conclusion

Situs inversus totalis may coincide with other conditions like amebic abscess and emphysematous gallbladder, complicating diagnosis and treatment. Early diagnosis and prompt intervention are crucial to improve outcomes.

Highlights

• Situs inversus totalis is a rare congenital condition characterized by the complete mirror-image reversal of organs.

• The presence of surgical gastrointestinal disease in a patient with situs inversus presents a surgical challenge.

• Medical team should collaborate in diagnosing and treating gastrointestinal illnesses in a patient with situs inversus.

Keywords

Situs inversus totalis
Amebic liver abscess
Emphysematous cholecystitis
Case report
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pmc1 Introduction

Situs inversus totalis is an uncommon congenital anomaly characterized by a complete reversal of both the abdominal and thoracic organs in a mirror-image transposition [1]. This condition can be classified into situs inversus with dextrocardia or with levocardia [2]. There are two case reports of situs inversus totalis with amoebic liver abscess in the previous literature [3,4]. This case report has been reported in line with the SCARE criteria [5]. Herein, we report a 65-year-old male with situs inversus totalis, an amoebic liver abscess, and an emphysematous gallbladder. To the best of our knowledge, this is the first case report in the previous literature.

2 Presentation of case

A 65-years-old male presented to the emergency department with complaints of abdominal pain, constipation, vomiting, and jaundice. He had been managing his diabetes for the past 10 years. Physical examination revealed pallor, tachypnea, tenderness, discomfort in the epigastric and left hypochondrium regions, there was gradual development of abdominal bloating, and he had a fever. Respiratory and cardiac examination were normal but the patient exhibited dextrocardia. The laboratory tests were performed [Table 1]. Left hypochondrium echography revealed a hydrops distention of gallbladder measuring approximately 10 × 5 cm, wall thickness of 1 cm, emphysematous changes were observed, sludge and multiple tiny stones with an average size of 2–3 cm, and surrounding fat stranding seen around common bile duct (CBD) dilated about 10 mm at distal part but no stone detected due to bowel obscure vision. The patient exhibited complete situs inversus of the organs. Chest and abdominal computerized tomography (CT) revealed complete situs inversus, an emphysematous gallbladder, suspicion of an anterior subcapsular hepatic abscess, and a dilated common bile duct (CBD) measuring about 8–9 mm. Additionally, bilateral mild pleural effusion and atherosclerotic changes were noted, no metastases or mass lesions were detected, and all other findings were normal (Fig. 1). The patient was administered a course of pre-operation antibiotics, which are Levofloxacin, linezolid, and tienam. Under general anesthesia, the patient underwent laparoscopic surgery, but it was stopped due to intra-abdominal adhesions and the challenging laparoscopy procedure in this case (Supplementary Video S1). For these reasons, it was decided to switch from laparoscopic surgery to open surgery. Left Kocher incision was performed, upon gaining access to the liver and gallbladder, observed a subcapsular liver abscess, and a distended necrotic gallbladder with adhesions. Open drainage of the liver abscess revealed chocolate-colored foul pus, indicative of an amebic liver abscess (Fig. 2). Subtotal cholecystectomy was performed due to the obscured anatomical structures of the hepatocystic triangle. Necrotic gallbladder tissue was resected (Fig. 3), a Foley catheter inserted into the gallbladder remnant, and the residual gallbladder remnant was sutured. The patient started to take postoperative antibiotic therapy with metronidazole and cefepime. Bacteriological examination of the pus was negative. Histopathological examination showed acute gangrenous cholecystitis with perforation and serositis, and secondary liver abscess. A seroma appeared as a surgical complication in the incision and was drained. Endoscopic retrograde cholangiopancreatography (ERCP) was performed postoperatively due to suspicion of the presence stone (due to bowel obscure vision) in CBD with dilation of approximately 10 mm that was observed in a prior ultrasound, revealing a normal biliary tree without evidence of choledocholithiasis, sphincterotomy and biliary drainage were performed to decrease the pressure and reduce biliary leakage from the residual gallbladder, as well as to prevent the formation of a biloma. (Fig. 4 + Video 1). The patient was followed with a CT scan, echography, and laboratory test 15 days post-operation. CT-scan revealed either untreated residuals of the hepatic abscess, edema in the liver abscess site, or the site of fluid drainage (Fig. 5). Liver function tests and complete blood count were normal, but the amylase and lipase levels were elevated as a result of the ERCP procedure for 3 days and then returned to normal. CBD was normal, no free fluid was seen, and no evidence of relapse or presence liver abscess on echography. The abscess liver drain was removed 5 days post-surgery, while the Foley catheter (in the residual gallbladder) was removed 48 h after ERCP (14 days post-surgery) due to cessation of bile leakage, and seroma drain was removed (Fig. 6). Subsequently, he was discharged in a good situation (Fig. 7).

3 Discussion

The situs inversus is a rare congenital disease with unknown etiology [2,3]. Its frequency is estimated at 0.001–0.01 %, it is often found accidentally during a radiological examination [3]. The amoebic liver abscess (ALA), which can be caused by the infection with the protozoan parasite Entamoeba histolytica, is a common disease in the tropics, and it represents the most common extra-intestinal complication of amoebiasis [6,7]. Amoebiasis leads to 100,000 deaths globally each year. Most of these deaths occur as a result of complications from amoebic colitis and amoebic liver [7]. Emphysematous cholecystitis (EC) is a rare lethal form of acute cholecystitis presenting mainly in male patients aged 50–70 years, and mostly occurring in patients with diabetes mellitus, immunosuppressed and peripheral vascular disease [6]. In situs inversus most patients are symptom-free [8]. EC starts with acute cholecystitis accompanied by ischemia or gangrene of the gallbladder wall and infection caused by gas-producing bacteria. The more common symptoms include right upper quadrant pain, low-grade fever, nausea, and vomiting. Peritoneal signs can exist, and masses in the right upper quadrant may be palpated in approximately half of patients [9]. For liver abscess and EC, the most causative organisms include Enterobacteriaceae (includes E.coli, Serratia, Klebsiella, Enterobacter, Citrobacter), Enterococci, Bacteroides, Entamoeba Histolytica, Clostridium welchii, Clostridium perfringens, and Streptococci [2,10]. However, clinical diagnosis may be hard before computed tomography [3], therefore we confirmed our diagnosis after the radiological examination and during the urgent operation. To detect EC, Diagnostic imaging like ultrasound and CT is the best way because ultrasonography shows a characteristic effervescent gallbladder and a CT scan demonstrates gas in the lumen and wall of the gallbladder in addition to a gas-fluid level [10]. For amoebic abscess in 25 % of cases, no past infection can be observed (cryptogenic abscess) [2]. The diagnosis of ALA has significantly evolved through the use of imaging and molecular biology techniques. Studies have reported that ultrasound examination has a sensitivity of >90 % for detecting ALA and is highly recommended as a first-line investigation. PCR is more sensitive in diagnosing ALA, and bacterial culture of the aspirate can assist in ruling out a pyogenic abscess [7]. cholecystectomy which can traditionally performed by laparotomy, is the selective treatment for EC, but for patients in poor condition, another option that can be performed is cholecystostomy as a temporary choice to control sepsis [10]. Due to advances in laparoscopic surgery, emergency cholecystectomy through a minimally invasive approach while respecting the fundamental surgical principles used in open surgery became possible [10]. Surgery can be a real challenge in patients with situs inversus totalis because of the structural anatomical inversion. Surgeons use their left hand to retract the gallbladder infundibulum through the epigastric port and their right hand for dissection through the left midclavicular port. This technique is usually used on patients in a supine position. In these cases, there is no one technique for all patients. So, the surgeon should adopt the procedure through their diligence to enable meticulous dissection and obtain a critical view of safety [11]. In our case and because of the intra-abdominal adhesions and the complexity of the laparoscopy procedure, the patient subsequently underwent open surgery. Aspiration, percutaneous drainage, and open surgical drainage are the interventional modalities available for complicated ALA [7]. Medical treatment is the best choice for ALA. On the other hand, and because of the size and number of abscesses sometimes a surgical or ultrasound, or scan-guided drainage can be performed [3] Percutaneous catheter drainage (PCD) is better than percutaneous needle aspiration, especially in a larger abscess (>10 cm), subcapsular location, high-risk for rupture, and if superinfected. Even for complications like rupture into the peritoneum, there is evidence that the results of management with PCD are better outcomes than surgery [12]. After the surgery the patient made a good postoperative recovery, not requiring admission to the intensive care unit.Fig. 1 Chest and abdominal computerized tomography (CT) revealed complete situs inversus; the red arrow showed a suspicion of an anterior sub-capsular hepatic abscess measured 62 × 50 × 37 mm; the blue arrow showed a distended gallbladder measuring approximately 10 × 4 cm with multiple tiny stones measuring 3 mm, along with surrounding fat stranding. These findings suggested emphysematous gallbladder. A: CT-scan showed situs inversus totalis with dextrocardia; B: CT-chest scan revealed dextrocardia; C: Coronal view of CT-scan; D: Transversal view of CT-scan. (For interpretation of the references to colour in this figure legend, the reader is referred to the web version of this article.)

Fig. 1

Fig. 2 Intra-operation images showed drainage of chocolate-colored foul pus from the abscess liver. A: Initial drainage of abscess liver; B: Completion drainage of abscess liver.

Fig. 2

Fig. 3 Intra-operation images showed necrotic gallbladder tissue, subtotal cholecystectomy, and residual gallbladder remnant suturing. (A-B): Image demonstrating gallstone extraction; C: Subtotal cholecystectomy procedure; D: Partial gallbladder after excision.

Fig. 3

Fig. 4 A: Common bile duct showed enhancement after injecting the contrast material; B: Sphincterotomy procedure; C: Biliary drainage after sphincterotomy; D: This image showed Ampulla.

Fig. 4

Fig. 5 CT-scan post-operation showed partial gallbladder after excision without any fluid around the gallbladder place, red arrow indicates an either potential partial resolution of the liver abscess, edema in the liver abscess site, or the site of fluid drainage. A: Sagittal view of CT-scan; B: Transverse view of CT-scan. (For interpretation of the references to colour in this figure legend, the reader is referred to the web version of this article.)

Fig. 5

Fig. 6 A: Images of the patient showed follow-up after surgery with drainages; B: Image of the patient showed the follow-up 16 days post-surgery. C: Excreta collection bag with fluids that drained from the liver abscess and gallbladder.

Fig. 6

Fig. 7 Timeline of the patient from presentation to discharge.

Fig. 7

Table 1 Laboratory test before surgical operation.

Table 1Test	Value	Normal range	
Hematology	
Hemoglobin (g/dl)	8.4	12.0–16.0	
RBC (106μl)	2.62	3.5–5.5	
Hematocrit (%)	23.2	36–46	
MCH (pg)	32.1	25–35	
MCV (fl)	88.5	80–100	
MCHC (g/dl)	36.2	32–36	
WBC (103μl)	22.5	4.4–11	
Neutrophiles (%)	51.86	50–70	
Lymphocytes (%)	6.37	20–45	
Monocytes (%)	41.37	2–8	
Eosinophils (%)	0.14	1–6	
Basophils (%)	0.26	0–2	
ESR (mm/1 h)	100	0.00–10.00	
PLT (103μl)	444	150–400	
PT (s)	12.4	10–15	
PTT (s)	35.3	24–36	
PTT ratio	1.22	–	
INR	1.13	0.8–1.5	
D-Dimers (μg/ml)	3.2	> 0.5	


	
Liver Function Tests	
Albumin (g/dl)	2.62	3.3–5.0	
Total protein (g/dl)	5.52	6.6–8.7	
ALP (IU/l)	184	40–129	
ALT (IU/l)	73	10–41	
AST (IU/l)	125	15–40	
Direct Bilirubin (mg/dl)	2.56	< 0.30	
Total Bilirubin (mg/dl)	2.83	< 1.1	
GGT (IU/l)	140	10–50	
HBsAg	Negative	N/A	
Anti-HCV	Negative	N/A	


	
Others Tests	
Typhoid IGM	Negative	N/A	
Typhoid IGG	Negative	N/A	
RBC: Red blood cells, MCH: Mean corpuscular hemoglobin, MCV: Mean corpuscular volume, MCHC: Mean corpuscular hemoglobin concentration, WBC: White blood cells, ESR: Erythrocyte sedimentation rate, PLT: Platelet count, PT: Prothrombin Time, PTT: Partial thromboplastin time, ALP: Alkaline Phosphatase, ALT: Alanine Trans Aminase, AST: Aspartate Trans Aminase, GGT: Gamma Glutamyl Transferase.

4 Conclusion

Situs inversus totalis, a rare congenital anomaly, may coincide with conditions like amebic abscess and emphysematous gallbladder, complicating diagnosis and treatment. Collaborating with specialists including radiologists, surgeons, and gastroenterologists is crucial for effective management.

The following are the supplementary data related to this article.Supplementary Video 1

Laparoscopic procedure revealing intra-abdominal adhesions.

Supplementary Video 1

Video 1

ERCP procedure revealed normal biliary tree without evidence of choledocholithiasis after surgery.

Video 1

Consent

Written informed consent was obtained from the patient for publication and any accompanying images. A copy of the written consent is available for review by the Editor-in-Chief of this journal on request.

Ethical approval

This paper was exempt from ethical approval because it does not include any personal information inside it.

Funding

No funding applicable.

Declaration of competing interest

The authors have no conflicts of interest.

Acknowledgements

No Acknowledgements applicable.

Author contribution

S.I. Conceptualization, Data curation, Writing – review & editing, Investigation, Supervision. Y.A. Data curation, Writing - original draft, Writing – review & editing. A.S.S. Writing – original draft, Writing – review & editing. S.H. Writing – original draft. M.A. Investigation.
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