Image in Medicine
When hepatoma rupture happens in situs inversus totalis: side matters M.-S. Pan1, C.-C. Shiao2,3, Y.-M. Chang2 1
Division of Cardiology, 2Division of Nephrology, Department of Internal Medicine, Saint Mary’s Hospital Luodong, Yilan, Taiwan, 3Saint Mary’s Medicine, Nursing and Management College, Yilan, Taiwan The authors reported a 73-year-old alcoholic man with previously-unrecognized situs inversus totalis suffering from left upper quadrant pain. Acute myocardial infarction was diagnosed and coronary angioplasty was performed immediately. However, the massive bleeding from the previously-unfound hepatomas caused hypovolemic shock and fatal outcome. Situs inversus totalis is a rare congenital anomaly with a complete mirror image of the thoracic and abdominal organs. Although being considered a benign entity, it would disturb diagnosis-making of the visceral diseases owing to the altered anatomy. To our knowledge, the coexistence of the coronary artery disease and ruptured hepatomas in situs inversus totalis, as in our patient, is never described. Recognition of any situs anomalies in time is the key to avoid misdiagnosis, inappropriate managements, and unwanted consequences.
Keywords: Acute myocardial infarction, Dextrocardia, Hepatoma, Situs inversus totalis
A 73-year-old chronic alcoholic man presented with left upper quadrant (LUQ) dull pain for 1 day. Acute inferior–posterior wall myocardial infarction in dextrocardia was diagnosed by chest radiography (Fig. 1), right side electrocardiography (ST-elevation in leads II, III, aVF; ST-depression with T-inversion in leads V2–3), and elevated cardiac biomarkers [troponin-T 2.57 (reference, ,0.02) mg/l; creatine kinase 1167 (reference, 20–170) and creatine kinaseMB 115 (reference, ,3) U/l]. The subsequent coronary angioplasty revasculized the 73% stenotic left circumflex artery bringing a stable post-procedure condition until 1 day later when hypovolemic shock occurred. The following emergent contrast-enhanced computed tomography disclosed several hepatomas (arrowheads) with hemorrhage (arrows) in the ‘leftsided’ cirrhotic liver of the patient with situs inversus totalis (Fig. 2A and B). Despite emergent hemostasis by transcatheter arterial embolization and intensive management, the patient died on the twentieth hospital day for nosocomial infection with multiple organ failure. Situs inversus totalis is a complete mirror image of the thoracic and abdominal viscera. It is a rare congenital abnormality occurring in one out of 5000 to 10 000,1 while the coexistence of acute myocardial
Correspondence to: Chih-Chung Shiao, Division of Nephrology, Department of Internal Medicine, Saint Mary’s Hospital Luodong, 160 Chong-Cheng South Road, Loudong 265, Yilan, Taiwan. Email: chun [email protected]
ß Acta Clinica Belgica 2015 DOI 10.1179/2295333714Y.0000000087
infarction and hepatoma rupture in situs inversus totalis is never reported previously. In our case, the initial presentation of LUQ pain raised the suspicion of heart disease rather than liver disease in ‘normal’ population. Although the diagnosis of acute myocardial infarction in the ‘right-sided’ heart was established, the multiple hepatomas in the cirrhotic ‘left-sided’ liver which might be already ruptured causing the LUQ pain is unrecognized. As a result, the heparin prescribed in the coronary angioplasty may be responsible for the consequent hepatomas bleeding and the fatal outcome. Practically, the relevant anatomic position is very important for
Figure 1 Chest radiography of a 73-year-old man presenting with left upper quadrant pain revealed dextrocardia.
Acta Clinica Belgica
2015
VOL.
70
NO.
2
149
Pan et al.
Hepatoma rupture in situs inversus totalis
Figure 2 The axial (A) and coronal (B) view of the contrast-enhanced computed tomography revealed several hepatomas (arrowheads) with hemorrhage (arrows) in the ‘left-sided’ cirrhotic liver.
physicians in making diagnosis. Recognition of any situs anomalies in time is necessary to avoid misdiagnosis and unwanted consequences.
150
Acta Clinica Belgica
2015
VOL .
70
NO .
2
References 1 Niki Y, Shiraki K, Enokimura N, Okano H, Yamanaka T, Takase K, et al. Hepatocellular carcinoma associated with situs inversus totalis. J Clin Gastroenterol. 2004;38(4):382–3.
When hepatoma rupture happens in situs inversus totalis: side matters M.-S. Pan1, C.-C. Shiao2,3, Y.-M. Chang2 1
Division of Cardiology, 2Division of Nephrology, Department of Internal Medicine, Saint Mary’s Hospital Luodong, Yilan, Taiwan, 3Saint Mary’s Medicine, Nursing and Management College, Yilan, Taiwan The authors reported a 73-year-old alcoholic man with previously-unrecognized situs inversus totalis suffering from left upper quadrant pain. Acute myocardial infarction was diagnosed and coronary angioplasty was performed immediately. However, the massive bleeding from the previously-unfound hepatomas caused hypovolemic shock and fatal outcome. Situs inversus totalis is a rare congenital anomaly with a complete mirror image of the thoracic and abdominal organs. Although being considered a benign entity, it would disturb diagnosis-making of the visceral diseases owing to the altered anatomy. To our knowledge, the coexistence of the coronary artery disease and ruptured hepatomas in situs inversus totalis, as in our patient, is never described. Recognition of any situs anomalies in time is the key to avoid misdiagnosis, inappropriate managements, and unwanted consequences.
Keywords: Acute myocardial infarction, Dextrocardia, Hepatoma, Situs inversus totalis
A 73-year-old chronic alcoholic man presented with left upper quadrant (LUQ) dull pain for 1 day. Acute inferior–posterior wall myocardial infarction in dextrocardia was diagnosed by chest radiography (Fig. 1), right side electrocardiography (ST-elevation in leads II, III, aVF; ST-depression with T-inversion in leads V2–3), and elevated cardiac biomarkers [troponin-T 2.57 (reference, ,0.02) mg/l; creatine kinase 1167 (reference, 20–170) and creatine kinaseMB 115 (reference, ,3) U/l]. The subsequent coronary angioplasty revasculized the 73% stenotic left circumflex artery bringing a stable post-procedure condition until 1 day later when hypovolemic shock occurred. The following emergent contrast-enhanced computed tomography disclosed several hepatomas (arrowheads) with hemorrhage (arrows) in the ‘leftsided’ cirrhotic liver of the patient with situs inversus totalis (Fig. 2A and B). Despite emergent hemostasis by transcatheter arterial embolization and intensive management, the patient died on the twentieth hospital day for nosocomial infection with multiple organ failure. Situs inversus totalis is a complete mirror image of the thoracic and abdominal viscera. It is a rare congenital abnormality occurring in one out of 5000 to 10 000,1 while the coexistence of acute myocardial
Correspondence to: Chih-Chung Shiao, Division of Nephrology, Department of Internal Medicine, Saint Mary’s Hospital Luodong, 160 Chong-Cheng South Road, Loudong 265, Yilan, Taiwan. Email: chun [email protected]
ß Acta Clinica Belgica 2015 DOI 10.1179/2295333714Y.0000000087
infarction and hepatoma rupture in situs inversus totalis is never reported previously. In our case, the initial presentation of LUQ pain raised the suspicion of heart disease rather than liver disease in ‘normal’ population. Although the diagnosis of acute myocardial infarction in the ‘right-sided’ heart was established, the multiple hepatomas in the cirrhotic ‘left-sided’ liver which might be already ruptured causing the LUQ pain is unrecognized. As a result, the heparin prescribed in the coronary angioplasty may be responsible for the consequent hepatomas bleeding and the fatal outcome. Practically, the relevant anatomic position is very important for
Figure 1 Chest radiography of a 73-year-old man presenting with left upper quadrant pain revealed dextrocardia.
Acta Clinica Belgica
2015
VOL.
70
NO.
2
149
Pan et al.
Hepatoma rupture in situs inversus totalis
Figure 2 The axial (A) and coronal (B) view of the contrast-enhanced computed tomography revealed several hepatomas (arrowheads) with hemorrhage (arrows) in the ‘left-sided’ cirrhotic liver.
physicians in making diagnosis. Recognition of any situs anomalies in time is necessary to avoid misdiagnosis and unwanted consequences.
150
Acta Clinica Belgica
2015
VOL .
70
NO .
2
References 1 Niki Y, Shiraki K, Enokimura N, Okano H, Yamanaka T, Takase K, et al. Hepatocellular carcinoma associated with situs inversus totalis. J Clin Gastroenterol. 2004;38(4):382–3.
