Chilaiditiʼs Syndrome: Unusual Cause of Abdominal Pain

Abstract

Background: Chilaiditi syndrome is the association of Chilaiditi sign with clinical symptoms including gastrointestinal, respiratory, or cardiac systems. Chilaiditi sign is the finding of colon between the diaphragm and liver on radiographic imaging, mimicking the appearance of air under the diaphragm. Clinical symptoms typically seen include nausea/vomiting, abdominal pain, and constipation. Here, we present a case of Chilaiditi syndrome that was diagnosed during workup for vague abdomen pain. Case Description: An 83 year old female with medical history of hypertension, type 2 diabetes mellitus, osteoporosis, rheumatoid arthritis, deep vein thrombosis with an IVC filter who complained of diffuse abdominal pain with occasional non-bloody vomiting for the 1 month duration. She also complained of chronic constipation and usually has only 1 to 2 bowel movements a week. Patient did not complain of any other symptoms. Initial exam revealed abdomen that was soft with diffuse tenderness upon palpation without any guarding or rebound. Rectal vault was full of formed stool. Vital signs and all other parts of physical exam were within normal limits. Initial abdominal x-ray showed possible air under the diaphragm. A follow-up CT scan of the abdomen/pelvis showed dilated rectum measuring 9.7 cm. The hepatic flexure was noted to be between the liver and the right diaphragm, suggestive of Chilaiditi syndrome (Fig. 1 and 2). Patient was manually disimpacted, which improved her symptoms. She declined additional workup with colonoscopy. Finally, she was given polyethylene glycol17 mg PO daily or BID, high fiber diet and was discharged home. Discussion Abdominal pain and emesis for a month along with finding of hepatic flexure located between the right diaphragm and the liver makes this case presentation a rare case of Chilaiditi syndrome. The exact etiology of this condition is not fully understood, however it is more commonly noted in patients with dolichocolon, COPD, hepatic atrophy. The plain x-ray findings of pneumoperitoneum could be confused for bowel perforation and CT scan of abdomen will help to differentiate it from Chilaiditi syndrome. Complications of Chilaiditi syndrome include volvulus or perforation of the transverse colon, ascending colon and cecum and can also lead to sub-diaphragmatic appendicitis. Management of Chilaiditi syndrome includes intravenous fluids, decompression of the bowel, stool disimpaction and enemas.FigureFigure: Hepatic flexure located between the liver and the right diaphragm.