Chilaiditi Syndrome & Double Balloon Colonoscopy

Abstract

Purpose: A 76 yo African American man presented with a 10 year history of constipation. He also had described numerous evaluations for multiple episodes of partial bowel obstructions, with symptoms consistent with obstipation. His only surgical history was a right nephrectomy for renal cell carcinoma. Colonoscopy was extremely technically difficult due to severe tortuosity of the colon. Advancement in the area of the hepatic flexure was difficult and the Olympus OPD positioning detecting unit was inserted, the scope tip appeared to be in the area of the right nipple. The procedure was aborted out of concern for a diaphragmatic hernia, and a virtual colonography was performed to evaluate the remainder of the colon for pathology and to define the anatomic layout of the colon. Virtual colonography demonstrated the hepatic flexure colon segment passing lateral, then superior and finally anterior to the liver. In addition, there was 12 × 5 mm pedunculated polyp in the ascending colon. There was no evidence for a diaphragmatic hernia. A double balloon colonoscopy was the performed with the intent of polyp removal. The cecum was comfortably reached without fluoroscopy. The ascending polyp was more easily approached in the retroflexed position and was removed using a saline lift piecemeal polypectomy. Final pathological diagnosis was tubular adenoma. Chilaiditi's syndrome is defined as interposition of bowel between the liver and right hemi-diaphragm. The syndrome has a low prevalence rate, which has been estimated to be between 0.1–0.25% of reviewed chest x-rays. It is associated with a number of abnormalities including chronic constipation, absence of transverse colon or falciform ligaments, chronic lung disease, hemi-diaphragm paralysis, ascites and/or cirrhosis. Complications can range from bowel puncture during liver biopsy, misdiagnosis of pneumoperitoneum or large bowel volvulus. There are few examples in the endoscopic literature to note that Chilaiditi's syndrome may be an unrecognized cause of a “difficult” colonoscopy. There are no prior examples of double balloon technique successfully facilitating colonoscopy completion with Chilaiditi's syndrome.Figure