Iatrogenic Chilaiditi Syndrome: A Rare Cause of Acute Abdominal Pain Following Colonoscopy Successfully Treated with Decompressive Colonoscopy with CO2 Insufflation

Abstract

Introduction: Chilaiditi syndrome is an abnormal interposition of bowel between the liver and diaphragm. It can be mistaken for pneumoperitoneum, or associated with volvulus or bowel ischemia. Three cases of iatrogenic Chilaiditi syndrome have been reported and one of these was associated with colonoscopy. This case illustrates post-colonoscopy iatrogenic Chilaiditi syndrome that was successfully treated with decompressive colonoscopy. Case: A 26-year-old woman was referred by her primary care physician for upper endoscopy (EGD) and colonoscopy to evaluate epigastric pain, nausea, vomiting, diarrhea, and weight loss. An outpatient CT scan was normal. On pre-procedure examination, the abdomen was soft and non-tender. EGD revealed gastric erosions, and biopsies were positive for Helicobacter pylori. The colonoscopy was mildly difficult due to looping. A collapsed lumen was noted at the hepatic flexure. Manual pressure was applied, and the cecum and terminal ileum were intubated and biopsied. In the post-procedure recovery, the patient complained of sharp right upper quadrant pain that radiated to her back. On exam, she was in distress, tachycardic, and writhing in pain. There was localized tenderness to palpation in the right upper quadrant with no rebound or guarding. An urgent CT scan was ordered to evaluate for colonoscopy complications. The CT identified new interposition of the colon between the liver and inferior aspect of the diaphragm without viscous perforation, and the diagnosis of Chilaiditi syndrome was made. Conservative measures with simethicone, ambulation, and attempts to expel retained air were unsuccessful. The decision was made to repeat the colonoscopy using carbon dioxide (CO2) insufflation for decompression. Following the decompressive colonoscopy, the pain had resolved and the patient was resting comfortably, and her heart rate normalized. The condition was explained to the patient, and she was advised that future colonoscopies should be performed cautiously and with the use of CO2 insufflation. Conclusion: Chilaiditi syndrome is a rare condition, with fewer than 200 cases reported. Iatrogenicallyinduced Chilaiditi syndrome has only been reported once as a complication of colonoscopy. In that case, the diagnosis was made several days after the colonoscopy, and the patient was ultimately treated with surgical pexy of the right colon. This case illustrates the importance of recognizing Chilaiditi syndrome as a cause of acute right upper quadrant pain following colonoscopy, and the success of immediate endoscopic decompression with CO2 insufflation. This case also supports the use of CO2 insufflation to minimize complications associated with colonoscopy.