Esfinterotomía biliar en litiasis coledociana en paciente con situs inversus total: a próposito de un caso / Case study of a sphincterotomy to remove stones from the common bile duct cholelithiasis biliary in a patient with total situs inversus

RESUMEN

El situs inversus es una condición autosómica recesiva caracterizado por imagen en espejo de órganostorácicos y abdominales. Se clasifica en situs inversus total y parcial. En el primero existe una transposicióncompleta de órganos torácicos y abdominales mientras que en el parcial existe compromiso de una o variasvísceras. Ej. Dextrocardia. La incidencia varía de 0,002 a 1%; por lo general, esta entidad no afecta la longevidaddel individuo pero la clínica del paciente es diferente y de no contar con un diagnóstico previo puedesorprender al endoscopista o cirujano. Se reporta caso de paciente femenina de 38 años, quien consulta pordolor en cuadrante abdominal superior izquierdo tipo cólico biliar con perfil hepático alterado, se realiza USA(ultrasonido abdominal) litiasis vesicular + colédoco dilatado + transposición de hígado y vesícula biliar alcuadrante abdominal superior izquierdo. Se planifica CPRE (colangiopancreatografía retrógrada endoscópica),solicitando valoración cardiovascular evidenciando dextrocardia en Rx de tórax PA. Con la tomografíaabdominal computarizada se corrobora el situs inversus total. En la colangiorresonancia se observa dilataciónde tercio distal de colédoco con dos litos en su interior. Se realiza CPRE visualizando papila mayor a la derechacon rotación de 180°, se realiza esfinterotomía biliar y se extraen los litos de colesterol. De allí la importanciadel diagnóstico preoperatorio para conocer el abordaje de la vía biliar en pacientes con dicha entidad

ABSTRACT

Situs inversus is an autosomal recessive condition characterized by of thoracic and abdominal organs in mirror image locations. It is classified into total and partial situs inversus. There is a complete transposition of thoracic and abdominal organs in total situs inversus while there is partial transposition of one or more organs in partial situs inversus. The incidence of this condition ranges from 0.002% to 1%. Although this entity does not usually affect an individual’s longevity, the patient’s clinical picture is different than that of other people. Consequently when the condition has not already been diagnosed, an endoscopist or surgeon is likely to be surprised. We report the case of a 38 year old female patient who consulted for pain in the left upper abdominal quadrant. She suffered from biliary colic and had an altered liver profile. Abdominal ultrasound showed transposition of the liver and common bile duct to the upper left abdominal quadrant as well as a dilated common bile duct with gallstones. ERCP (endoscopic retrograde cholangiopancreatography) was requested. Cardiovascular assessment with chest x-ray showed dextrocardia. Abdominal computed tomography corroborated the diagnosis of total situs inversus. An MRCP (Magnetic Resonance Cholangiopancreatogram) showed dilation of the distal common bile duct within which were two stones. An ERCP showed that the papilla was larger on the right and was rotated 180°. A sphincterotomy was performed, and the cholesterol stones were extracted. This case shows the importance of preoperative diagnosis for addressing the bile duct in patients with situs inversus