Therapeutic ERCP in patient with situs inversus totalis and ampullary diverticulum

Situs Inversus Totalis (SIT) is a rare entity with complete transposition of all viscera, making endoscopic and surgical procedures challenging and complicated. We describe a rare case of a 55 years old man with SIT and ampullary diverticulum presenting with cholangitis and deranged liver function tests due to common bile duct stones. Therapeutic Endoscopic Retrograde Cholangiopancreatography (ERCP) was planned to relieve biliary obstruction and removal of stones. Procedure was started after informed consent in usual left semi-prone position but rotation of scope to 180 degrees and shortening under fluoroscopic guidance was done to attain and maintain desirable ampullary position and cannulation was done with standard sphincterotome followed by sphincterotomy and sphincteroplasty. ERCP was performed successfully despite difficulties of dual pathology and the patient made uneventful recovery.