Open Journal of Radiology
Vol.07 No.03(2017), Article ID:78698,6 pages
10.4236/ojrad.2017.73018
Chilaiditi Syndrome
Jean Marie Ovungu1*, Pierlesky Elion Ossibi2, Franck Mvumbi1, Ismael Dandakoye Soumana2, Badre Alami1, Meryem Boubbou1, Mustapha Maaroufi1, Khalid Mazaz2, Khalid Ait Taleb2, Youssef Lamrani1
1Department of Radiology, Hassan II University Hospital, Fez, Morocco
2Department of Visceral Surgery, Hassan II University Hospital, Fez, Morocco
Copyright © 2017 by authors and Scientific Research Publishing Inc.
This work is licensed under the Creative Commons Attribution International License (CC BY 4.0).
http://creativecommons.org/licenses/by/4.0/
Received: February 26, 2017; Accepted: August 21, 2017; Published: August 24, 2017
ABSTRACT
The interposition of the colon or the small intestine between the liver and the diaphragm otherwise called Chilaiditi syndrome remains a rare condition. Its incidence varies between 0.025% and 0.28% according to recent literature and is only found incidentally on diagnostic imaging. Hence, it constitutes a classic pitfall in the diagnosis of false right pneumoperitoneum. We deem interesting to report a case of Chilaiditi syndrome in a 44-year-old patient with no significant history who was admitted at emergency department for abdominal trauma following a road accident.
Keywords:
Chilaiditi, Interposition, Colon, Small Intestine, Diaphragm, Liver Imaging
1. Introduction
Chilaiditi syndrome is a condition characterized by the interposition of colon or small intestine between the liver and the diaphragm. It is a condition first described in 1865 by Cantini. However, it was only in 1910 that Demetrius Chilaiditi reported 3 cases of patients with radiological evidence of colonic interposition between the diaphragm and the liver [1] . Its discovery is most often incidental during chest or abdominal imaging. Chilaiditi sign is typical pitfall in the misdiagnosis of right false pneumoperitoneum. Global incidence of the malposition varies from 0.025% to 0.28% with a clear male predominance [2] . The affection is more common in the elderly. We hereby report the case of Chilaiditi syndrome in a 44-year-old patient with no significant history who presented at the emergency department with suspected abdominal trauma following a road accident.
2. Case Report
Patient, 44 years old with no significant clinical history admitted to emergency ward for abdominal trauma following a road accident. Symptoms dated back a few hours prior to his admission after patient was involved in a motorcycle collision with right-side impact on fall.
Physical examination found a conscious patient, stable vitals with abdominal examination revealing right upper quadrant tenderness.
Lab tests came back unremarkable.
Plain chest radiograph centered on the diaphragmatic dome revealed a gas shadow in the epigastric region (Figure 1).
Abdominal CT showed a colonic interposition between the liver and the diaphragm (Figures 2-4) without pneumatosis in the cavity and segment VI liver contusion.
Management entailed administration of intra venous analgesics and proton-pump inhibitors with close monitoring of vitals and biological markers.
Clinical course was uneventful with favorable outcome after conservative management.
3. Discussion
Chilaiditi syndrome is a rare condition. Globally, its incidence is estimated between 0.025% to 0.28% with the affection more common in adult males as was the case in our patient [2] .
Figure 1. Plain radiograph showing gas shadow between liver and diaphragm.
Figure 2. Abdominal CT showing colic interposition between liver and anterior abdominal wall.
Figure 3. Abdominal CT coronal section showing colic interposition between liver and diaphragm.
Figure 4. Abdominal CT sagittal section showing interposition of colic interposition between liver and diaphragm.
As per its pathogenesis, it is well established that normal embryological development of the liver as well as means of fixation of the intestine prevents interposition of the colon between the diaphragm and the liver. However, in certain rare anatomical variations, notably hypotrophy of the liver or agenesis of the right lobe of the liver, or in the event of elongation of the suspensory ligament of the liver, elongation of the colon (dolichocolon), poor fixation or poor position of the colon, congenital pathologies of the small intestine or diaphragm with elevation of the right hemidiaphragm (eventration), relaxation or agenesis of the suspensory ligament of the mesentery [3] [4] [5] the latter could occur. These factors may be present in 6% of patients at birth. On the other hand, in adults other factors including cirrhosis [6] , chronic constipation, increased abdominal pressure (pregnancy), obesity [7] , enlargement of the lower rib cage due to chronic obstructive pneumonitis with a large space in which the interposition of the colon may occur [1] are also believed to be contributory factors.
From a pathology standpoint, colonic segments involved in the interposition between the liver and the diaphragm or the abdominal wall are mostly the transverse colon, followed by the right colic flexure even though cases involving small intestine interposition have also been reported [7] .
Colonic interposition is often asymptomatic despite relative higher incidence of radiological evidence [8] .
As far as its diagnosis is concerned, interposition of the colon (Chilaiditi sign) is defined as the presence of a gas shadow below the right hemidiaphragm on plain abdominal X-ray. Positive diagnosis of Chilaiditi syndrome based on imaging requires the presence of the following criteria: elevation of the right diaphragmatic hemicoupola by the intestine, gas distension of the colon beneath the diaphragm, lowering of the upper margin of the liver than the level of the left diaphragmatic hemicoupola with no other positional anomalies [9] .
Differential diagnosis of the syndrome involves mainly pneumoperitoneum [10] [11] . In addition, changes in patient positions do not change the location of radiological evidence unlike in a patient with free air in the peritoneal cavity.
4. Conclusion
Chilaiditi syndrome is a rare pathological entity, discovered incidentally during diagnostic imaging and constitutes a major pitfall in the diagnosis of right false pneumoperitoneum.
Cite this paper
Ovungu, J.M., Ossibi, P.E., Mvumbi, F., Soumana, I.D., Alami, B., Boubbou, M., Maaroufi, M., Mazaz, K., Taleb, K.A. and Lamrani, Y. (2017) Chilaiditi Syndrome. Open Journal of Radiology, 7, 164-169. https://doi.org/10.4236/ojrad.2017.73018
References
- 1. Nitin, T., Sameer, S., Priyanka, S., Dinesh, M., Sachin, B., Neeraj, B., Sulbha, S. and Puneet, S. (2014) Coexistence of Pneumothorax and Chilaiditi Sign: A Case Report. Asian Pacific Journal of Tropical Biomedicine, 4, 75-77.
- 2. Cedrick, S.M., Maruis, K.F., Mireille, K.Z., Nelly, M.S., Patience, M.P., Shem, M., Chamy, C.L. and Josephine, M.K. (2014) Chilaiditi Syndrome in a Newborn, in Case Report. Pan African Medical Journal, 19, 239.
- 3. White, J.J., Chavez, E.P. and Souza, J. (2002) Internal Hernia of the Transverse Colon-Chilaiditi Syndrome in a Child. Journal of Pediatric Surgery, 37, 802-804.
https://doi.org/10.1053/jpsu.2002.32293 - 4. Orangio, Fazio, V.W., Winkelman, E. and McGonag, B.A. (1986) The Chilaiditi’s Syndrome and Associated Volvulus of the Transverse Colon: An Indication for Surgical Therapy. Diseases of the Colon and Rectum, 29, 653-656.
https://doi.org/10.1007/BF02560330 - 5. Plorde, J.J. and Raker, E.J. (1996) Transverse Colon Volvulus and Associated Chilaiditi’s Syndrome: Case Report and Literature Review. The American Journal of Gastroenterology, 91, 2613-2616.
- 6. Haddad, C.J. and Laclé, J. (1998) Chilaiditi’s Syndrome: A Diagnostic Challenge. Postgraduate Medical Journal, 9, 249-250.
- 7. Murphy, J.M., Maibaum, A., Alexander, G. and Dixon, A.K. (2000) Chilaiditi’s Syndrome and Obesity. Clinical Anatomy, 13, 181-184.
https://doi.org/10.1002/(SICI)1098-2353(2000)13:3<181::AID-CA4>3.0.CO;2-7 - 8. Cetin, D., Unubol, M., Soyder, A., Guney, E., Coskun, A., Ozbas, S., et al. (2012) Coexistence of Multiple Endocrine Neoplasia Type 2B and Chilaiditi Sign: A Case Report. Case Reports in Endocrinology, 2012, 360328.
- 9. Gupta, P.P. and Agarwal, D. (2011) Medical Image: Chilaiditi Syndrome. The New Zealandmedical Journal, 124, 81-83.
- 10. Farinella, E., Nazzaro, C., Rossetti, B., Giuliani, D., Giustozzi, G.M. and Sciannameo, F. (2006) Chilaiditi’s Syndrome: A Rare Cause of Abdominal Pain in the Differential Diagnosis of the Abdominal Perforation. Case Report Giornale di Chirurgia, 27, 417-421.
- 11. Moaven, O. and Hodin, R.A. (2012) Chilaiditi Syndrome: A Rare Entity with Important Differential Diagnoses. Gastroenterology and Hepatology, 8, 276-278.