Presentation
Upper abdominal pain. Soft abdomen on examination. No previous illness.
Patient Data
Bilateral tri-lobed lungs (two bilateral lung fissures - right and left). The left-sided fissure pattern is atypical. The bronchus/pulmonary artery relationships are conventional.
Normal heart.
Abdomen scan reveals right-sided polysplenia.
Left-sided IVC (inferior vena cava) with azygous continuation.
Large midline liver which spans the whole width of the abdomen.
Partial dorsal pancreatic agenesis.
Stomach seen in the right side.
Malrotation of the bowel. The duodenum does not pass between the SMA and aorta and the SMV lies to the right of the SMA.
Peripherally enhancing right adnexal lesion associated with minimal pelvic free fluid likely representing corpus luteum cyst.
Lumbosacral transitional vertebra on the left side.
Case Discussion
This pattern is referred to as situs ambiguus. Each lung has appropriate arteries, veins and main bronchi in the expected locations. This case cannot be classified as left or right isomerism which by definition has two left or two right-sided lungs with corresponding broncho-arterial relationships. However there is right-sided polysplenia along with associated findings of polysplenia syndrome 1. Cases are discovered by CT scan in adult life as an incidental finding. The associated findings should be documented; non-rotation or malrotation of the bowel in particular can cause complications and the altered anatomy could complicate abdominal surgery.
Ultrasound subsequently demonstrated an obstructing bile duct calculus which accounted for her abdominal pain.
Contributed by: Mohammed Ibrahim Abu Kamesh.
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