This is Mohammad Talal Sarmini. In this video, we're going to go over the technical endoscopic challenges in situs inversus totalus. On behalf of my co-authors, we have no financial disclosures to report. A 64-year-old female with known history of situs inversus, presented with right lower quadrant abdominal pain, Acolyte stools, jaundiced skin, and diffused pruritus. Labs showed elevated AST at 197, ALT 141, ALKFOS 814, and bilirubin 28.3. CT abdomen revealed 3.8 x 1.9 cm heterogeneous partially enhancing pancreatic mass, moderate intrahepatic biliary dilation with non-distended common bile duct. It showed also heterogeneously enhancing gallbladder wall thickening with a small amount of wall calcification. Situs inversus totalus is a rare congenital anomaly that consists of complete left-right inversion of the viscera. This condition imposes significant challenges understanding patient symptoms and interpreting imaging studies. It also increases the technical difficulties and the possibilities of complications of therapeutic and diagnostic interventions. Therefore, understanding the altered anatomy is essential to increase the success rate of therapeutic and diagnostic endoscopy and avoid complications. As we can see on this endoscopy, the endoscopist is heading into the thylorus, turning to the left side, which is mirrored compared to patients with normal anatomy. Also going to the duodenum, it's completely reversed compared to patients with normal anatomy. On AUS, we can see that the patient has normal pancreas with no mass. We can notice the thickened gallbladder wall with multiple large stones inside. On this window, we can see the common bile duct with significantly thickened wall and narrowed lumen. On both pole by view, we can see the common bowel duct again with thickened wall, normal pancreatic duct and normal pancreatic tissue. Given the biliary obstruction, ERCP was obtained and the patient was maintained on a left lateral position. The papilla was visualized at 2 o'clock compared to patients with normal anatomy where it's usually found at 10 o'clock. The bile duct was deeply cannulated and contrast was injected and extended to the entire biliary tree. The common bile duct contained a single diffused stenosis extending from the ampulla into the intrahepatic perforcation without enhancement of the cystic duct. It's worth mentioning that in this patient, common bile duct was accessed between 12 and 1 o'clock compared to patients with normal anatomy where it's usually accessed between 11 and 12 o'clock. Afterwards, sphincterotomy was performed. Cytology was obtained and temporary 7 French by 10 centimeter stent was placed into the biliary duct. Chloroscopy imaging confirmed the placement of the CBD stent. Cytology came back later positive for cholangiocarcinoma.

endoscopic procedures

situs inversus totalus

congenital condition

reversed anatomy

ERCP