Ambiguous Anatomy and Its Pain

Question: A 46-year-old woman presented to the emergency department with a 1-day history of sudden onset colicky central abdominal pain. She had been passing flatus until that morning and her last bowel motion was day before. tolerating diet without any nausea or vomiting. no significant medical otherwise previously fit well throughout life. previous surgery endoscopic procedures. an active smoker. Her vital signs were normal on surgical review. Initially she appeared comfortable however serial observations develop waves severe cramping There distension noted. abdomen generally tender maximally in epigastrium localized guarding. white cell count 12.9 × 109/L C-reactive protein 2.0 mg/L. serum electrolytes, renal function, liver function tests, lipase all normal. What would be causes pain patient grossly unremarkable laboratory investigations? See Gastroenterology web site (www.gastrojournal.org) for more information submitting your favorite image Clinical Challenges Images GI. computed tomography scan revealed whirlpool sign small mesentery relation superior mesenteric artery unusual anatomical findings viscera (Figure A). The entirety noted left compartment. colon right caecum sitting midline sigmoid against pelvic sidewall. enlarged spanned entire upper B). porta hepatis gallbladder midline. several splenunculi quadrant consistent polysplenia. stomach duodenojejunal flexure sided. pancreatic head inferior C). tail aorta vena cava appropriately positioned within abdomen. These midgut volvulus context newly discovered situs ambiguous taken emergently operating theatre diagnostic laparoscopy, which confirmed contained its own peritoneal sac D). prophylactic laparoscopic appendicectomy performed. Conversion laparotomy performed owing distorted atypical anatomy. containing opened revealing mildly congested E). Ladd’s band identified from at ileocecal junction contributing volvulus. divided untwisted pedicle F, demonstrating held by forceps). placed position minimal torsion. moved iliac fossa transverse unmoved centrally. Ultimately, new intestinal configuration like found inversus.1Applegate K.E. Goske M.J. Pierce G. et al.Situs revisited: imaging heterotaxy syndrome.Radiographics. 1999; 19: 837-852Crossref PubMed Scopus (210) Google Scholar,2Ghosh S. Yarmish Godelman A. al.Anomalies visceroatrial situs.AJR Am J Roentgenol. 2009; 193: 1107-1117Crossref (27) Scholar recovered discharged postoperative 6. To our knowledge, this is first described case phenomenon. surgeon gastroenterologists, it important aware patients anomalies anatomic challenges presents.