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Situs ambiguus in a Brown Swiss cow with polysplenia: case report



Laterality defects are rare in cattle and usually manifest as asplenia orpolysplenia syndrome. These syndromes may be associated with situs ambiguus,which is a dislocation of some but not all internal organs. The objective ofthis report was to describe the clinical and post-mortem findings includingthe macroscopic and microscopic anatomy of selected organs in a cow withpolysplenia and situs ambiguus.

Case presentation

A 3.5-year-old Brown Swiss cow was referred to the Department of FarmAnimals, Vetsuisse Faculty, University of Zurich, because of poor appetiteand recurrent indigestion. A diagnosis of situs ambiguus was based on theresults of physical examination, ultrasonography, exploratory laparotomy andpost-mortem examination. The latter revealed that the rumen was on the rightside and lacked compartmentalisation. There were two spleens, one on theleft (26.5 x 12.0 cm) and one on the right (20.5 x 5.5 cm), and the omasumwas located craniolateral to the ruminoreticulum on the left. The abomasumwas located on the right, although it had initially been displaced to theleft. The three-lobed liver occupied the left and central cranioventralaspect of the abdominal cavity (cavum abdominis). Only the right and lefthepatic veins (vena hepatica dextra and sinistra) drained into the thoracicsegment of the caudal vena cava (vena cava caudalis), and histologicalchanges in the liver were indicative of impaired haemodynamics. Themesojejunum was not fused with the mesentery of the spiral loop (ansaspiralis) of the ascending colon (colon ascendens). The latter was foldedand the transverse colon (colon transversum) ran caudal to the cranialmesenteric artery (arteria mesenteria cranialis). Fibrotic constrictionswere seen in the lumen of the caecum and proximal loop (ansa proximalis) ofthe ascending colon. Both kidneys were positioned retroperitoneally in alumbar position. The lumbar segment of the caudal vena cava did not descendto the liver and instead drained into the right azygous vein (vena azygosdextra).


Recurrent digestive problems and poor production in this patient may havebeen caused by a lack of rumen compartmentalisation, abnormal abomasalmotility, constrictions in the large intestine (intestinum crassum) andfibrosis of the liver. The abomasum had abnormal motility most likelybecause it was anchored inadequately and only at its cranial aspect to theliver by the lesser omentum (omentum minus) and to the dorsal abdominal walland rumen by a short greater omentum (omentum majus).


Laterality defects are very rare in domestic animals. Situs inversus is the mostcommon laterality defect in dogs [14] and horses [5]. Primary ciliary dyskinesia (PCD) also known as Kartagener’ssyndrome [3, 5, 6], is thought to be the primary cause of this condition, which is oftenassociated with recurrent chronic respiratory problems including bronchiectasia andchronic rhinitis. The few reports on laterality defects in ruminants deal withpost-mortem findings in cattle and sheep [711]. There have been only two cases of heterotaxy(“heteros” = other and“taxis” = arrangement) described in cattle and they werereferred to as situs inversus [7, 8], although at least one of these reports was restricted to intra-thoracicorgans, and both were not well documented. The anatomical findings in most of thedocumented cases [911] can be best characterised as situs ambiguus, which can be divided intoasplenia (right isomerism) and polysplenia (left isomerism). These conditions arealso assumed to be morphological correlates of PCD in humans [1215]. It has been shown that several gene defects are correlated with PCD andthus with laterality defects [12, 1619]. In humans, PCD is a genetically heterogeneous disorder with an autosomalrecessive mode of inheritance in most cases [14, 15, 19].

To the authors’ knowledge, this is the first detailed case report of a situsambiguus in a cow. Because not all organs were reversed from their normal positions,and some organs had specific deviations from normal in addition to heterotaxy, thiscase was not diagnosed as situs inversus. The findings serve to expand our knowledgeabout the clinical signs, functional implications and topography of internal organsin cattle with situs ambiguus.

Case presentation

Animal and methods

A three-year-old, non-pregnant primiparous Brown Swiss cow, which had previouslyproduced a live calf was referred to the Department of Farm Animals, VetsuisseFaculty, University of Zurich, because of poor body condition and a tentativediagnosis of caecal dilatation. The cow was small for its age and therefore bredlate, resulting in an age at first calving of 39 months. The cow was often seenruminating but had a history of poor appetite, and production during earlylactation was two thirds of the herd average. The cow resumed ovarian cyclicityand was inseminated twice post partum but did not conceive. The animal underwentclinical and ultrasonographic examinations and blood was collected forhaematological and biochemical analyses. Haematocrit, total leukocyte count andthe concentrations of fibrinogen and total protein from EDTA blood samples weredetermined on an automated blood analyser (CELL-Dyn 3500, Abbott DiagnosticsDivision, Baar). The concentrations of serum bilirubin, urea nitrogen, sodium,chloride, potassium, calcium, inorganic phosphorus and magnesium were determinedat 37°C using an automated analyser (Cobas-Integra-800-Analyser, RocheDiagnostics, Basel) and the manufacturer’s reagents (Roche-Reagents)according to the International Federation of Clinical Chemistry and LaboratoryMedicine (IFCC). Rumen fluid was collected using a stomach tube and the chlorideconcentration measured with an MK-II-Chloride Analyser 9265 (Sherwood,Cambridge). Results were compared with reference values established at thisclinic.

A standing right-flank exploratory laparotomy was done because of apparentabnormalities in the topography of the abdominal organs, suspected caecaldilatation and left displacement of the abomasum. During laparotomy it wasconfirmed that the abdominal organs were arranged in a mirror image reversal ofthe normal positioning. The left dorsal displacement of the abomasum wascorrected and the general condition of the patient improved and the cow wasdischarged five days postoperatively.

The cow was re-admitted to the clinic 2.5 months later because she failed to gainweight and milk production remained poor. Because of a grave prognosis, the cowwas euthanised, exsanguinated, fixed in standing position with 2.8% formaldehydeadministered through the common carotid artery (arteria carotis communis), andnecropsied. Samples of the mucosa of nasal conchae (conchae nasales), frontalsinus (sinus frontalis) and trachea were collected and routinely processed forscanning and transmission electron microscopy for the examination of thepresence and structural integrity of ciliated cells. Samples of liver tissue andof two control livers of non-liver-diseased cows ageing five and six years werecollected, fixed in 10% formalin, embedded in paraffin and routinely processedfor light microscopy and immunohistochemistry. Staining with haematoxylin andeosin, Gomori’s blue trichrome (Artisan™, Dako) andreticulin-nuclear fast red stains (Foot, Artisan™, Dako), histochemicaldetection of bilirubin (according to Hall), copper (rhodamine method for copper)and ferric iron pigments (Iron stain, Artisan™, Dako) andimmunohistochemical detection of α-smooth muscle actin (monoclonal mouseanti-human alpha muscle actin, clone 1A4, Dako) and desmin (monoclonal mouseanti-human desmin, clone D33, Dako) were carried out at the Institute ofVeterinary Pathology, University of Zurich using standard protocols. Cytokeratin(mouse anti-human cytokeratin, MNF1166, Dako) and von Willebrand factorimmunohistochemistry (polyclonal rabbit anti-human von Willebrand factor, Dako)were done to distinguish vessels from bile ducts. The size of 20 liver lobulesfrom this cow as well as from two healthy controls, aged five and six years, wasmeasured histomorphometrically using AxioVison software (Release 4.63, Zeiss),means and standard deviations were calculated, and differences analysed using anunpaired t-test (Statview 5.0 for Windows).

Clinical findings during the first hospitalisation

Auscultation on the left revealed no ruminal contractions and showed that thecontent of the digestive tract exhibited no layered arrangement at this site.Faeces had normal consistency and colour.

Ultrasonographic examination revealed that the heart had a normal size and shapeand the large vessels were positioned normally within the thoracic cavity (cavumthoracis). The rumen was large and gas-filled and only a few loops of the smallintestine (intestinum tenue) could be seen on the right side of the abdominalcavity. There were three reticular contractions during a two-minute period. Theliver was visible ventrally on the left side of the abdominal cavity and thegall bladder (vesica fellea) was moderately enlarged.

Exploratory laparotomy revealed a heterotaxy of abdominal organs. The rumen wasalmost empty and situated on the right side of the abdominal cavity. Thereticulum was attached to the rumen cranioventrally and contained sand. Theomasum was to the left of the rumen and had a firm consistency. The abomasum hada normal size, was on the left side and displaced dorsally. It contained a smallamount of firm and doughy ingesta. The intestines were to the left of the rumen,almost empty and had good peristalsis. The distal half and the tip of the caecum(apex caeci) had a normal size and shape. The greater omentum, which normallyforms the supraomental recess (recessus supraomentalis) containing theintestines in ruminants, was not detected during surgery (see post-mortemfindings). The abomasum was repositioned ventrally in the abdomen before closureof the abdominal wall.

Serum biochemistry analysis on the day of initial hospitalisation showed aslightly increased bilirubin concentration as well as increased activities ofglutamate dehydrogenase, aspartate aminotransferase and creatine kinase. Theactivity of sorbitol dehydrogenase was moderately increased and the activity ofgamma-glutamyltransferase was severely elevated. The cow also had a hypokalaemicand hypochloraemic metabolic alkalosis. The chloride concentration of theruminal fluid was normal (Table 1).

Table 1 Biochemical analysis of selected variables in serum and ruminalfluid

The general condition of the cow improved postoperatively, and one to two ruminalcontractions per minute could be ausculatated one day after surgery. The cow wasdischarged five days postoperatively, but was readmitted 2.5 months laterbecause of failure to gain weight and poor milk production.

Clinical findings during the second hospitalisation

The findings after re-admission to the clinic were similar to those of theinitial physical examination with regard to the forestomach, abomasum, whichstill had a ventral position, and intestines. Percussion and ultrasonographyrevealed that the liver was located in the ventral median part of the abdominalcavity directly caudal to the diaphragm.

Post-mortem findings

Respiratory system

There were no macroscopic signs of acute or chronic inflammation of themucosa of the nasal cavity, frontal sinus, larynx and trachea. Both lungswere of normal size and had only two anomalies (Figure 1): the apex of the cranial part of the cranial lobe of theright lung (pars cranialis lobus cranialis pulmonis dextri) was bentdorsally resulting in a V-shaped appearance. The accessory lobe (lobusaccessorius pulmonis dextri) was small. Light and transmission electronmicroscopy revealed normal tracheal and nasal ciliary morphology andultrastructure. The number of cilia-bearing cells varied among differentspecimens and within single specimens. Scanning electron microscopy showed afew epithelial cells with long and thick apical protrusions representingclotted cilia. Adjacent to these cells were epithelial cells that had intactcilia and some that had microvilli.

Figure 1
figure 1

Right (A) and left (B) lungs, lateral view. 1 Cranial lobe,cranial part; 2 Cranial lobe, caudal part; 3 Caudal lobe; 4 Middlelobe; 5 Accessory lobe, reduced size. Note the apex of the cranialpart of the cranial lobe in A, which was bent dorsally resulting ina V-shaped appearance.

Digestive system

The anatomy and topography of the digestive tract from the oral cavity to thediaphragm was normal. Within the abdominal cavity there were strikingdeviations relating to the shape and position of the digestive organs. Thereticulum and rumen occupied the right abdomen (Figures 2 and 3). The reticulum was cranial and tothe left of the rumen. The reticular groove (sulcus reticuli) was 31 cmlong. The reticular mucosa was normal with characteristic polygonal cells.The rumen had a normal mucosa but lacked pillars (pila ruminis) and hencelacked compartmentalisation. However three low transverse folds were notedon the interior of the floor (Figure 4). These folds,from cranial to caudal, were 39, 64 and 69 cm long and the distances betweenthem were 36 and 16 cm respectively. Cranially, the rumen was attached tothe dorsal wall of the abdominal cavity.

Figure 2
figure 2

Relationship of abdominal organs, drawing, right view. 1Rumen; 2 Reticulum; 3 Omasum, located left of reticulum; 4–5Abomasum: 4 Body, 5 Pylorus; 6–8 Duodenum (left side): 6Initial straight part, 7, 8 U-shaped loop; 9 Jejunum (left side); 10Ileum (left side); 11 Caecum (left side); 12–13 Ascendingcolon (left side): 12 Proximal loop, 13 Distal loop; 14 Transversecolon; 15 Descending colon; 16 Rectum; 17 Right ovary; 18 Uterus; 19Urinary bladder; 20 Right spleen; 21 Liver; 22 Pelvic symphysis.

Figure 3
figure 3

Abdominal and thoracic cavities, lungs, diaphragm and heartremoved, right view. 1 Rumen; 2 Reticulum; 4 Abomasum; 20Right spleen; 21 Liver; VI 6th rib.

Figure 4
figure 4

Rumen interior, dorsal view, cranial is right. Normalcompartmentalization by pillars is lacking. Note three transversefolds 1–3 on floor of rumen.

Two spleens lay on and were attached to the rumen craniodorsally and to thedorsal abdominal wall. The larger spleen measured 26.5 × 12.0 cm andwas on the left and the small right one measured 20.5 × 5.5 cm (Figure5). The cranioventral wall of the rumen wasconnected to the abomasum by a short peritoneal fold of the greater omentum.The omasum was cranioventrally and to the left of the rumen and caudal tothe liver (Figure 2). The abomasum was on theabdominal floor in a bent position ventral to the omasum and the rumen(Figures 2 and 3). It wasloosely attached to the liver by mesogastrium, which originated from thelesser curvature (curvatura minor) of the abomasum and represented thelesser omentum (omentum minus). The abomasal greater curvature (curvaturamajor) was orientated caudally (Figures 2 and 3) and was connected loosely to the cranioventral aspectof the rumen and the dorsal abdominal wall by the greater omentum (omentummajus). Thus the ventral part of the rumen was not enclosed by the greateromentum, which normally forms the omental bursa (bursa omentalis) and isattached to the abomasum (Figures 3, 6 and 7).

Figure 5
figure 5

Rumen with two spleens, dorsal view, cranial is right. 1 Rightruminal artery and vein; 2 Left ruminal artery; 3 Left spleen; 4Right spleen.

Figure 6
figure 6

Relationship of abdominal organs, drawing, stomach and spiralcolon removed, all organs located at the left side, leftview. 1 Liver, Left lobe; 2 Left spleen; 3–5 Duodenum:3 Initial straight part, 4, 5 U-shaped loop; 6 Jejunum; 7 Ileum;8–8′: Caecum, 8 Body, 8′ Apex; 9–10Ascending colon: 9 Proximal loop, 10 Distal loop; 11 Transversecolon; 12 Descending colon; 13 Rectum; 14–15 Strictures: 14 inCaecum, 15 in Proximal loop; 16 Left ovary; 17 Uterus; 18 Vagina; 19Urinary bladder; 20 Pelvic symphysis; 23 Caudal vena cava.

Figure 7
figure 7

Abdominal and thoracic cavities, lungs, diaphragm and heartremoved, left view. 1 Liver, Left lobe; 2 Left spleen;4–5 Duodenum, U-shaped loop; 6 Jejunum; 8′ Apex of theCaecum; 10 Ascending colon, Distal loop; 12 Descending colon; 19Urinary bladder; 21 Left kidney; 22 End of Esophagus; 23 Caudal venacava, arising from Left and Right hepatic veins; 24 Descendingaorta; 25 Mesenteric root.

The duodenum had an initial straight part arising from the pylorus andrunning dorsally. It was continued by a U-shaped loop extending to the leftcranial side of the abdominal cavity (Figures 6 and7). The jejunum was in the left ventral quadrantof the abdominal cavity and formed many short coils. The mesojejunum was notfused with the mesocolon ascendens (Figures 6 and7). The ileum arose from the jejunum in the leftcaudoventral abdominal cavity and ran cranially to join the large intestineat the ileal opening (ostium ileale) just cranial to the caecocolic opening(ostium caecocolicum) (Figures 2, 6 and 8).

Figure 8
figure 8

Relationship of abdominal organs, drawing, stomach and duodenumremoved, all organs located on left side, right view. 1Jejunum; 2 Ileum; 3 Caecum; 4–8 Ascending colon: 4 Proximalloop, 4′ End of Proximal loop; 5–7 Spiral loop: 5In-going coils, 6 Central flexure, 7 Out-going coils; 8 Distal loop(left side).

The caecum was located on the left side near the median plane atmid-abdominal level with its tip extending caudally (Figures 6, 7, 8 and 9). The ascending colon could be divided into proximal,spiral and distal loops (ansa proximalis, spiralis, and distalis coli)(Figures 7, 8 and 9). The proximal loop was S-shaped and continued cranially onthe right as spiral loop, which was situated near the median plane. Themesojejunum was not fused with the part of the mesocolon ascendens thatfixes the spiral loop. The normally flattened, discoid and sagittallyextending spiral loop was folded such that the cranial and caudal rims ofthe disc were fused, which resulted in a characteristic bi-layeredintestinal complex (Figures 8 and 9). The caudal margin of the spiral loop was thus adjacent andfixed to its cranial margin resulting in a semicircular structure. Thedistal loop was U-shaped, started with a cranially running section, had anascending cranial loop and led to the transverse colon (colon transversum)dorsocaudally (Figures 7 and 8).There were two fibrosed strictures associated with the large intestine. Oneinvolved the caecum and the other involved the beginning of the proximalloop of the ascendic colon (Figure 6). The transversecolon crossed the midline from the left to right caudal to the cranialmesenteric artery (arteria mesenterica cranialis). The descending colon(colon descendens) originated on the right side, but the anatomy andposition of the remainder of the descending colon as well as the rectum werenormal.

Figure 9
figure 9

Abdominal and thoracic cavities, stomach, lungs, diaphragm andheart removed, right view. 1 Jejunum; 3 Caecum; 4–8ascending colon: 4′ end of Proximal loop; 5 In-going coils ofSpiral loop; 9 Liver, Right lobe; 10 Right kidney; 11 Urinarybladder; 12 Cranial mesenteric artery; 25 Broad ligament; 26Mesenteric root; 27 Diaphragm, Right crus; VI 6thrib.

The mesenteric root (radix mesenterii) was situated in the midline betweenthe crura of the diaphragm and cranial to the kidneys (Figures 7 and 9).

The liver had transversally orientated dorsal (margo dorsalis) and ventralborders (margo ventralis), a ventromedian position immediately caudal to thediaphragm (Figures 6, 7, 9 and 10) and was composed of twolarge lobes and a very small lobe (Figure 11, seeAdditional file 1: Figure S1 and Additional file2: Figure S2). The right lobe (lobus dexter)was larger than the left lobe (lobus sinister). The very small lobe waslocated infraportally between the larger two lobes, cranial and right to theround ligament (ligamentum teres hepatis), right to the fissure of the roundligament (fissura ligamentum teretis) and the falciform ligament (ligamentumfalciforme hepatis) and left and cranial to the gallbladder (vesica fellea)and the cystic duct (ductus cysticus). This small and cylindric lobe had atriangular basis on the visceral side, extended to the ventral border (margoventralis) and the diaphragmatic side of the liver demonstrating atriangular rounded and dome-like shape (Figure 11,see Additional file 2: Figure S2). The dorsal(margo dorsalis) and the ventral borders (margo ventralis) of the liver weretransversally orientated.

Figure 10
figure 10

Relationship of selected abdominal and thoracic organs, drawing,right view. 1 Diaphragm; 2–5 Heart: 2 Left ventricle,3 Right ventricle; 4 Right atrioventricular (tricuspid) valve; 5Right atrium; 6 Cranial vena cava; 7 Right azygous vein, enlarged; 8Caudal vena cava, draining into the Right azygous vein; 9 Caudalvena cava; 10, 11 Veins draining the gastrointestinal organs; 12Portal vein; 13 Hepatic branches; 14 Coeliac artery; 15 Cranialmesenteric artery; 16 Caudal mesenteric artery; 17 Liver; 18Rumen.

Figure 11
figure 11

Liver, cranial view, after dissection of the venous drainage.1 Right lobe; 2 Left lobe; 3 Quadrate lobe; 4 Right hepatic vein; 5Left hepatic vein; 6 Anastomosis between 4 and 5; 7 Gallbladder.

The liver received blood from two large gastrointestinal veins (Figure 10, see Additional file 3:Figure S3), which joined to form a very short (7.0 cm) portal vein (venaportae) with a large diameter (3.5 cm), which was subcapsular and nearlycompletely intrahepatic (Figure 10, see Additionalfile 3: Figure S3 and Additional file 4: Figure S4). Two large branches were dispatched(right 15 mm, left 7 mm) (Figure 10, see Additionalfile 4: Figure S4) which supplied their respectivelobes. Many small branches (2 to 4 mm in diameter) arose from the two largehepatic branches, as well as, from the portal vein (Figure 10, see Additional file 4: Figure S4).The round ligament, the falciform ligament, the gallbladder and the cysticduct were in close proximity. The gallbladder was slightly enlarged (Figure11, see Additional file 1: Figure S1). Left and right hepatic veins (vena hepaticasinstra and dextra), joined to form the caudal vena cava. A largeanastomosis was present near the ventral border of the liver (Figure 11). The caudal vena cava - arising solely from the twomajor hepatic veins in this animal - passed through the diaphragm via thecaval foramen (foramen venae cavae) and joined the right atrium of the heart(Figures 10 and 12).

Figure 12
figure 12

Thoracic cavity, lung removed, right view. 1 Diaphragm;2–4 Heart: 2 Left ventricle, 3 Right ventricle; 4 Rightatrium; 5 Caudal vena cava; 6 Right azygous vein, enlarged; 7Trachea; 8 Tracheal bronchus; 9 Division of the Chief bronchus intoCaudal and Middle bronchus; 10 Oesophagus; VI 6thrib.

Histologically, the hepatic lobules (lobuli hepatici) had a normalarchitecture (Figure 13, see Additional file 5: Figure S5), but had two or three central veins(venae centrales) compared with only one in control livers. The width of thehepatic lobules (radius = 461 ± 150 μm)was significantly (p < 0.0001) reduced compared with twocontrol livers (672 ± 88 μm and710 ± 184 μm). The enlarged portal fields (seeAdditional file 6: Figure S6) had two to sixarterioles, one thin-walled venule and one or several lymphatic vessels,which were sometimes mildly dilated. Moderate periportal fibrosis,consisting of coarse collagen fibres and proliferating fibroblasts (Figure13, see Additional file 6: Figure S6), and moderate hyperplasia of small biliaryductules (ductuli biliferi) were also prominent features (see Additionalfile 6: Figure S6). There were relatively fewinflammatory cells (mainly lymphocytes and plasma cells), which was similarto the control livers. The number of biliary ductules was increased but theductual lumina were normal (see Additional file 6:Figure S6). There was no increase in connective tissue or reticular fibresintralobularly (Figure 13, see Additional files7: Figure S7 and 8:Figure S8). However, a thick mesh of actin filaments was diffusely presentalong the sinusoids (see Additional file 9: FigureS9), but not in the controls (see Additional file 10: Figure S10). There was no increased immunoreaction againstdesmin. No bilirubin, copper and ferric iron pigments were detected in theadjacent hepatocytes.

Figure 13
figure 13

Photomicrograph of liver. Gomori’s blue trichrome staindemonstrates increased periportal connective tissue.

Cardiovascular system

The anatomical features and position of the heart were normal. The abdominalcavity demonstrated one striking abnormality of the venous drainage of thetrunk, pelvic limbs, kidneys, and pelvic organs. This large venous trunk(caudal vena cava) did not descend to the dorsal margin of the liver, drainthe liver, pass through the diaphragm and end in the right atrium of theheart. Instead it connected with the right azygous vein as it passed betweenthe crura of the diaphragm, below the vertebral column (columna vertebralis)on the right surface of the descending aorta (aorta descendens). Thisenlarged right azygous vein drained into the right atrium of the heart(Figures 10 and 12, seeAdditional file 11: Figure S11).

Both ruminal arteries (Aa. ruminales dextrae et sinistrae) run along thecraniodorsal wall of the rumen to the right and left side of this organ andproceeded caudally giving rise to dorsal and ventral branches (Figure 5).

Urogenital system

Both kidneys were positioned retroperitoneally; the left kidney was furthercranial than the right kidney, which represented an abnormal position(Figures 7 and 9).


In ruminants, the most common manifestation of heterotaxy of internal organs appearsto be situs ambiguus, which is divided into two primary subtypes: Asplenia syndromeor right isomerism, and Polysplenia syndrome or left isomerism [911]. Situs inversus, however, describes a situation in which all visceralorgans are reversed or mirrored from their normal position (referred to as situssolitus [13]) and is considered extremely rare in ruminants [7, 8]. To our knowledge, there have been three cases of asplenia, six cases ofhypoplastic spleens, 15 cases of two spleens and only two cases of situs inversusdescribed in cattle [7, 8, 10, 11]. The main findings in our patient (continuation of the caudal vena cavainto the right azygos vein, polysplenia, continuation of a common hepatic vein intothe right atrium, heterotaxia of the digestive tract, tri-lobed liver,retroperitoneal position of both kidneys, positioning of the left kidney cranial tothe right kidney and normal anatomy and topography of heart and lungs) were ingeneral agreement with other reports of polysplenia syndrome in cattle [10, 11] und thus strongly indicate the presence of this syndrome in our cow.Characteristics of the polysplenia syndrome in cattle - as reported in literatureand detected in this animal - are: continuation of the vena cava caudalis into thevena azygos dextra (n = 6; number of cases) or sinistra(n = 3), continuation of a common hepatic vein into the atrium dextrum(n = 4), situs inversus (n = 2) and left isomerism(n = 4) of the liver, situs inversus of the stomach (n = 2),retroperitoneal position of both kidneys (n = 1), positioning of theleft kidney cranial to the right kidney (n = 1) and normal anatomy andtopography of the lungs [10, 11].

Primary ciliary dyskinesia has been associated with chronic airway diseases andimpaired fertility in dogs, horses, and humans [13, 5, 1315, 20]. It is an unlikely cause of heterotaxy in cattle because in the patientdescribed in this report, there was no chronic respiratory disease and theultrastructure of the cilia was normal. Although fertility was severely reduced inthis cow, this does not support an etiological role of PCD since the cow wasinseminated late because of small size and did therefore produce a calf at 39 monthsof age. Because genetic and functional analyses were not carried out, PCD cannot beruled out in this case.

In humans, neonates with polysplenia syndrome have a high incidence of severe heartdisease and therefore high juvenile mortality. Only children without severecardiovascular defects and those in which cardiovascular defects are correctedimmediately after birth survive and reach adulthood. Therefore, in adults,polysplenia syndrome is clinically characterised by gastrointestinal heterotaxia andnon-life-threatening vascular abnormalities [13, 15, 18, 21, 22], which is similar to findings in our patient and in accordance withreports in the literature [10, 11]. Further investigations in neonate calves are needed to determine whethersimilar cardiovascular defects occur in cattle with polysplenia or aspleniasyndrome; unfortunately most calves that die shortly after birth because ofpostnatal asphyxia or cyanosis are not necropsied.

Many of the topographical abnormalities observed in the present case can be explainedby specific developmental stages of organs during embryogenesis. The topography ofthe liver in our patient was characteristic for the position of this organ in theperinatal period in cattle, indicating that the ruminant-specific shift to the rightside and anti-clockwise quarter-turn of the organ during the postnatal life had notoccurred [23]. The caudal vena cava is usually composed of a sequence of severalsagittal embryonic vessels [24]. The lack of connection or a faulty connection between the intra-hepaticor immediate post-hepatic parts of these sagittal veins results in a dorsalanastomosis between the right or left azygous vein and the abdominal segment of thecaudal vena cava. The latter vein therefore does not descend to the dorsal margin ofthe liver. This modification of vasculogenesis leads to a continuation of the caudalvena cava into the right azygous vein, which occurred in our patient and also inseveral other cattle [11]. The only function of the final segment of the caudal vena cava, whichran from the liver and passed through the diaphragm to join the right atrium of theheart, was drainage of the liver. From a functional point of view, it served as acommon hepatic vein.

The asymmetrical morphology of the tri-lobed liver was reflected by the specificdrainage of the two large lobes by two large hepatic veins, one on the right and oneon the left. This finding was also in agreement with the very small size of a liverlobe that possibly represent the quadrate lobe and the complete absence of thecaudate lobe (lobus caudatus), which are normally drained by the large middlehepatic vein (vena hepatica media) [25]. The specific anatomy of the liver and its midline position in theabdominal cavity support the concept of a polysplenia syndrome/left isomerism inthis animal.

The histological characteristics of the hepatic lobules were indicative of abnormalhaemodynamics. However, different types of haemodynamic changes may cause identicalstereotypical abnormalities in the portal triad (pattern of portal veinhypoperfusion) similar to those described in our patient. Causes of portal veinhypoperfusion include congenital portosystemic shunts, arterioportal fistulas andobstruction or hypoplasia of the portal vein. The macroscopic and histologicalchanges in the vasculature of our patient represented primary pre- and intra-hepatichypoplasia of the portal vein [26]. The changes in liver microstructure may also have reflected or causedthe poor nutritional status of this cow. Normal liver function is a prerequisite formany catabolic and anabolic processes, and abnormalities in serum enzyme activitiesand bilirubin concentration in this cow were characteristic of chronic impairment ofliver function [27]. There have been no previous reports of the histological changes in theliver of ruminants with situs ambiguus.


In the present case report, there were striking abnormalities in the anatomy,topography, fixation and thus mobility of the abdominal parts of the digestivetract, which resulted in obvious digestive malfunction, small body seize, poor bodycondition and low milk production of the cow.

These findings seen in our patient may have been caused by a number of factorsincluding the loose connection of the abomasum to the cranially situated abdominalorgans and wall and thus rendering susceptibility to dislocation and bloating,constrictions of the large intestine at the level of the caecum and the proximalloop of the ascending colon, and lack of normal ruminal compartmentalisation. Thelaboratory findings suggested reduced feed intake caused by mild abomasal refluxsyndrome and/or prolonged periods of recumbency. Whether liver abnormalitiescontributed to poor body condition is not clear. However, marked fibrosis of theliver reflected poor nutritional status and possibly chronically impairedmetabolism. The absence of inflammation and cholestasis and the presence ofarteriolar proliferation, hypoplastic venules, portal fibrosis and bile ductproliferation were indicative of abnormal haemodynamics.

It was surprising that the cow was able to produce a live calf, given that fertilitywas obviously impaired. Equally surprising was that the cow had ruminal contractionsand was seen by the owner to ruminate given the ruminal anomalies observed. Thenormal consistency of the faeces was an indication of a certain level of normalcy ofdigestive tract function.


Consent was obtained from the owner of the cow for publication of this casereport and any accompanying images.


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The authors thank Mrs. E Högger-Manser for her excellent technicalassistance.

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Correspondence to Alois Boos.

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The authors declare that they have no competing interests.

Authors’ contributions

AB carried out and supervised the postmortem examination of the cow’s thoraxand stomach, documented the postmortem findings, drafted major parts of themanuscript and searched and reviewed the literature. HG carried out and supervisedthe postmortem examination of the cow’s intestines, designed the schematicillustrations and drafted parts of the manuscript (the section on the intestines).UM carried out the postmortem examination. JP designed and made the schematicillustrations. TaS and MP carried out the clinical examinations and surgery. MR andTiS did the histological and immunohistochemical evaluations and drafted thecorresponding parts of the manuscript. CCS and CG were responsible forultrasonography of the heart and abdomen, respectively. EMS carried out andvalidated the ultrastructural assessments. UB initiated and supervised the casereport, performed the clinical examination, initiated surgery and supportedpreparation of the manuscript. All authors read and approved the finalmanuscript.

Alois Boos, Hans Geyer contributed equally to this work.

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Additional file 1: Figure S1: Liver, caudal view. 1 Left lobe; 2 Right lobe; 3 Minor omentum; 4Caudal vena cava with adherent rim of diaphragmatic tissue; 5 Gallbladder. (EPS 4 MB)


Additional file 2: Figure S2: Liver, cranial view. 1 Right lobe; 2 Left lobe; 3 Quadrate lobe; 4Caudal vena cava with adherent rim of diaphragmatic tissue; 5Falciform ligament. (EPS 20 MB)


Additional file 3: Figure S3: Liver, hilus, caudal view. 1 Hepatic lymph node; 2 Hepatic artery; 3Bile duct; 4, 4’ veins draining gastrointestinal organs. (EPS 7 MB)


Additional file 4: Figure S4: Liver, hilus dissected. 1 Liver, Left lobe; 2 Liver, Right lobe; 3Portal vein; 4 Left branch and 5 Right branch of 3; 6 Right branchof the hepatic artery; 7 Common hepatic duct; 8Cystic duct; 9 Gallbladder; 10 End of gastrointestinal veins. (EPS 7 MB)


Additional file 5: Figure S5: Photomicrograph of liver. Haematoxylin and eosin stain demonstrateshepatic lobules, duplications of central veins (arrows) andperiportal fibrosis (arrowheads). (EPS 2 MB)


Additional file 6: Figure S6: Photomicrograph of liver. Haematoxylin and eosin stain demonstrates aportal tract with fibrosis, proliferation of bile ducts (star),increased numbers of small arteries (arrow), and several crosssections of small thin-walled hepatic veins or lymphatic vessels(arrowhead). (EPS 2 MB)


Additional file 7: Figure S7: Photomicrograph of liver. Reticulin-nuclear fast red stain (Foot)demonstrates large amount of reticulin fibres within the portaltract. (EPS 2 MB)


Additional file 8: Figure S8: Photomicrograph of control liver. Reticulin stain (Foot) demonstratesa small amount of reticulin fibres along the sinusoids. (EPS 2 MB)


Additional file 9: Figure S9: Photomicrograph of liver. Immunohistochemical staining of alphasmooth muscle actin demonstrates large amounts of actin filaments inthe portal tracts, interlobularly and along the sinusoids. (EPS 2 MB)


Additional file 10: Figure S10: Photomicrograph of control liver. Immunohistochemical staining ofalpha smooth muscle actin demonstrates a small amount of signalalong the sinusoids. (EPS 2 MB)


Additional file 11: Figure S11: Thoracic cavity, lung removed, right view. 1 Right azygous vein,enlarged; 2 Middle mediastinal lymph node; 3 Caudal mediastinallymph node; 4 Thoracic duct; 5 Descending aorta; 6 Sympathetictrunk; 7 Dorsal branch of the right vagus nerve; 8 Trachealbronchus; 9 Right chief bronchus; 10 Oesophagus. (EPS 8 MB)

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Boos, A., Geyer, H., Müller, U. et al. Situs ambiguus in a Brown Swiss cow with polysplenia: case report. BMC Vet Res 9, 34 (2013).

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