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doi:10.1111/jgh.12491

E D U C AT I O N A N D I M A G I N G

Gastrointestinal: Endoscopic ultrasound of a pancreatic lesion in situs inversus a

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Figure 1

A 75 year old male with situs inversus presented with progressive epigastric pain, weight loss, and newly diagnosed diabetes mellitus over 4 months. Clinical examination revealed mild epigastric tenderness and dextrocardia, but was otherwise unremarkable. Liver enzymes were mildly deranged (Alkaline phosphatase 187 U/L, Gamma-glutamyl transpeptidase 57 U/L, Bilirubin 9 μmol/L). The CA 19.9 was elevated at 1455 U/mL. Multi-slice computed tomography revealed a 29mm partially cystic mass in the neck of the pancreas with features of situs inversus (Figures 1a and b). The patient underwent endoscopic ultrasound (EUS), by the linear echoendoscope initially with the patient in the conventional left lateral position. Due to alteration of the anatomical landmarks a radial echoendoscope was used to define the anatomy. All manoeuvers (both with the endoscope shaft and dials) were performed inversely as if a reflection of standard endoscopy. Identification of the vascular anatomy was challenging due to the leftright reversal, as seen imaging the great vessels (Figure 2a). Suboptimal views of the pancreas were obtained so the patient was placed in the right lateral position as per the “mirror image” technique, allowing the entire pancreas to be visualised. The pancreatic lesion was identified, abutting the hepatic artery but clear of the portal vein (Figure 2b). The linear echoendoscope was then

used to perform a FNA of this lesion in the conventional manner and this revealed malignant cells consistent with adenocarcinoma. This is the first report of EUS in situs inversus totalis. Situs inversus totalis is a rare autosomal recessive condition in which the abdominal and thoracic organs are transposed to the opposite side. The anatomical variation adds a particularly high degree of complexity to EUS, as the endoscopists is required to not only safely advance the endoscope through mirrored anatomy but also interpret the sonographic images where standard anatomical landmarks are reversed. Upper gastrointestinal endoscopy, including endoscopic retrograde cholangiopancreatography, has been successfully performed in patients with situs inversus with the patients kept in the conventional position. Recently however the “mirror image” technique has been described as a method of allowing successful passage of the endoscope through the upper gastrointestinal tract. This technique requires the patient to lie in the right lateral position and the endoscopist to perform all endoscopic manoeuvers as if a reflection of standard endoscopy. This practise requires that the insertion tube together with the left-right and up-down wheels move inversely during endoscope advancement to what would occur in a normal endoscopy. We illustrate in the above case that this technique can be used in situs inversus to improve both endoscopic positioning and sonographic visualization, thereby, allowing FNA to be performed. Contributed by V Kumbhari*, D Abi-Hanna*,† & M Bassan† *Division of Gastroenterology and Hepatology, Bankstown-Lidcombe Hospital and †Division of Gastroenterology and Hepatology, Liverpool Hospital, Sydney, New South Wales, Australia

Journal of Gastroenterology and Hepatology 29 (2014) 229 © 2014 Journal of Gastroenterology and Hepatology Foundation and Wiley Publishing Asia Pty Ltd

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Gastrointestinal: endoscopic ultrasound of a pancreatic lesion in situs inversus.

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