S1634 Chilaiditi Syndrome: Colonic Interposition Between the Liver and Right Hemidiaphragm

Abstract

INTRODUCTION: Chilaiditi’s sign is a rare radiological observation (incidence 0.025-0.3%) of colonic interposition between the liver and the diaphragm, and presents as gas under the diaphragm. When accompanied by symptoms such as abdominal pain, nausea, vomiting, and constipation, this is referred to as Chilaiditi syndrome. This syndrome is often misdiagnosed for serious abdominal conditions such as subphrenic abscess, pneumoperitoneum, or diaphragmatic hernia. This case presentation may help avoid misdiagnosis and guide management. CASE DESCRIPTION/METHODS: A 70-year-old man with a history of COPD presented to the emergency department with acute chest pain and dyspnea. He also reported chronic intermittent nausea, vomiting, and epigastric pain. Physical exam showed increased respiratory effort with diffuse wheezing, and tenderness in the epigastric and right upper quadrant regions without rebound tenderness or guarding. CBC, BMP, LFTs, troponin, lactate, and lipase were unremarkable. CXR revealed an abnormal gas shadow between the right diaphragm and liver, most suggestive for colonic interposition (Chilaiditi’s sign, Fig). Patient was diagnosed with a mild COPD exacerbation and discharged home with appropriate treatment. DISCUSSION: Chilaiditi syndrome is typically a benign condition, but more severe presentations include volvulus, intestinal obstruction, ischemia, and perforation. Some rare cases present with dyspnea and chest pain, as in this case. Risk factors include variations in normal anatomy (laxity of suspensory ligaments), chronic constipation, ascites (increased abdominal pressure), cirrhosis (liver atrophy), and chronic lung disease (increased intrathoracic pressure). Here, the most likely etiology was increased intrathoracic pressure secondary to COPD. Asymptomatic Chilaiditi’s sign may become syndromic due to sudden increased intrathoracic pressure with cough, such as a COPD exacerbation in this patient. Undiagnosed Chilaiditi’s sign may result in unnecessary surgery and increase the risk of perforation during colonoscopy or liver biopsy. Given patient’s mild presentation and presence of haustral markings on CXR, this case was fortunately not mistaken for a more serious entity. Conservative management was aimed at relieving pain, constipation, abdominal distention, and treating the COPD exacerbation. However, we recommend further imaging (US, CT) if CXR is not conclusive of Chilaiditi’s syndrome. 26% of cases require surgery when conservative treatment is unsuccessful.Figure 1.: CXR showing an abnormal gas shadow between the right hemidiaphragm and the liver, with clear haustral markings, suggesting colonic interposition (Chilaiditi’s sign).