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Chilaiditi's Sign and Syndrome: Theoretical Facts and a Case Report Chilaiditi-Jev Znak I Sindrom

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Chilaiditi's Sign and Syndrome: Theoretical Facts and a Case Report Chilaiditi-Jev Znak I Sindrom Vojnosanit Pregl 2016; 73(3): 277–279. VOJNOSANITETSKI PREGLED Page 277 UDC: 616.24-06:616.34 CASE REPORTS DOI: 10.2298/VSP140603052Z Chilaiditi's sign and syndrome: theoretical facts and a case report Chilaiditi-jev znak i sindrom Biljana Zvezdin*†, Nevena Savić*†, Sanja Hromiš*†, Violeta Kolarov*†, Djordje Taušan‡, Bojana Krnjajić*† *Institute for Pulmonary Diseases of Vojvodina, Sremska Kamenica, Serbia; †Faculty of Medicine, University of Novi Sad, Novi Sad, Serbia; ‡Pulmology Clinic, Military Medical Academy, Belgrade, Serbia Abstract Apstrakt Introduction. Chilaiditi's syndrome is a rare condition Uvod. Chilaiditi-jev sindrom je retko stanje koje se manifes- manifested by gastrointestinal symptoms, and radiologically tuje gastrointestinalnim simptomima, a radiološki se potvrđu- verified by transposition of the large intestine loop. This ra- je pozicioniranim vijugama creva u prostoru između jetre i diological finding with no manifested symptoms is termed desne hemidijafragme. Postojanje ovakvog radiološkog nalaza the Chilaiditi's sign. The aim of this case report was to re- i odsustvo simptoma naziva se Chilaiditi-jev znak. Cilj rada mind the clinicians of the possibility of this rare syndrome, bio je podsećanje kliničara na mogućnost postojanja tog ret- whose symptoms and signs may be misinterpreted and in- kog sindroma, koje može rezultirati pogrešnim tumačenjem adequately treated, with consequent diverse complications. simptoma i znakova bolesti, neadekvatnim lečenjem i različi- Case report. We presented the theoretical facts and a pa- tim komplikacijama. Prikaz bolesnika. Prikazane su teorijske tient in whom the diagnosis of Chilaiditi's syndrome was es- činjenice i bolesnik kod koga je dijagnoza Chilaiditi-jev sin- tablished incidentally, when hospitalized for an exacerbation drom postavljena prilikom hospitalizacije zbog pogoršanja of his chronic obstructive pulmonary disease. The Chilaid- hronične opstruktivne bolesti pluća. Chilaiditi-jev znak potvr- iti's sign was verified as an incidental finding on chest X-ray đen je kao slučajni nalaz na radiogramu grudnog koša nači- performed to evaluate the primary disease. Conclusion. njenom u cilju procene osnovne bolesti. Zaključak. Chilaidi- Chilaiditi's syndrome is a benign condition which rarely re- ti-jev sindrom je benigno stanje koje retko zahteva hiruršku quires surgery. Its clinical importance lies in adequate differ- intervenciju. Klinički značaj tog sindroma ogleda se u adekva- ential diagnostic approach and timely management of po- tnom diferencijalnodijagnostičkom pristupu i pravovreme- tentially serious complications. nom zbrinjavanju mogućih ozbiljnih komplikacija. Key words: Ključne reči: chilaiditi syndrome; diagnosis; diagnosis, differential; chilaiditi sindrom; dijagnoza; dijagnoza, diferencijalna; radiography; tomography, x-ray computed. radiografija; tomografija, kompjuterizovana, rendgenska. Introduction pneumoperitoneum 4, 5. Treatment is usually conservative, or surgical in case of complications 4–9. Chilaiditi's syndrome is a very rare condition, character- ized by the presence of different symptoms due to either Case report temporary or permanent malposition of the colon loops in between the liver and the right hemidiaphragm 1–9. This ra- A old-75-year patient, was admitted to the Institute for diological finding accompanied with no symptoms is called Pulmonary Diseases of Vojvodina, Sremska Kamenica, Ser- Chilaiditi's sign 1, 3–9. The etiology of this anatomic anomaly bia, due to exacerbation of his chronic obstructive pulmonary is still unknown, and considered multifactorial. The syn- disease, outpatiently treated for over twenty years. Having drome is manifested by isolated or concurrent symptoms – responded poorly to the intensified ambulatory desobstructi- gastrointestinal, pulmonary, and/or cardiac, of different in- on treatment, the patient was referred to hospital. He was tensity and frequency 4. The differential diagnosis includes a presented with a variety of comorbidities, including arterial variety of diseases of numerous organ systems, primarily the hypertension, atrial fibrillation, valve defect, abdominal her- Correspondence to: Biljana Zvezdin, Institute for Pulmonary Diseases of Vojvodina, Institutski put 4, 21 204 Sremska Kamenica, Serbia. Phone: +381 21 4805 128. E-mail: [email protected] Page 278 VOJNOSANITETSKI PREGLED Vol. 73, No. 3 nia, cholelithiasis, prostatic hyperplasia, degenerative spinal Echocardiography verified ejection fraction of 50%, disease, depression. The patient complained on the symptoms paradoxical septal movements, initial concentric hypertrophy of cough, dyspnea, fatigue, heart palpitations and arrhythmia, of the left ventricle myocardium, sclerosis of aortic valves, mi- occasional pains below the right rib arch, and dyspeptic prob- tral regurgitation 3+. The treatment included inhalant and par- lems. On admission, the patient was conscious, oriented, enteral desobstructive therapy, gastroprotective medication, exhausted, moving with difficulties, afebrile, dyspnoic, nor- peroral anticoagulant therapy and other formerly prescribed mocardic, normotensive, with no signs of cardiac decompensa- cardiological therapy. The gastroenterologist was consulted, tion, giving the impression of a moderately severe patient. On who recommended conservative treatment measures and ad- auscultation, bronchospasm signs were registered. The abdo- vised to consult the abdominal surgeon in case of an acute ex- men was at the level of the chest, soft on palpation, with a re- acerbation of gastrointestinal symptoms. The applied treatment ponible hernia of the anterior abdominal wall, and a mildly pa- improved the patient's general and respiratory condition, and inful, sensitive epigastric region, audible peristalsis, and no he was discharged with recommendations for further ambula- signs of meteorism or ascites. The chest X-ray finding was tory treatment, and instructed what to do in case of exacer- presented with bilateral striped paracardial lesions, adhering bated respiratory and gastrointestinal symptoms. hemidiaphragms, and the presence of an air collection below the right hemidiaphragm (Figure 1). Discussion Chilaiditi's sign is an incidental radiological finding, pre- sented as a crescent lucency below the diaphragm on the right, occurring due to malpositioned loops of the colon and/or small intestine.5 It was for the first time described by Cantini in 1865 but the first three case reports were published by the Greek ra- diologist Demetrius Chilaiditi in 1910, after whom this condi- tion has been named 2, 3. Its incidence ranges from 0.025% to 0.028% 3. In males and the elderly, it is registered four times as frequently as in other population groups, the incidence amounting to around 1% 3, 4. Being an asymptomatic condi- tion, its diagnosis is established incidentally, on the occasion of different radiological examinations of the chest or abdomen 7 (CT, standard chest X-ray, or ultrasound) . Fig. 1 – The chest x-ray reveals air collection below the right Predisposing factors include all the conditions resulting hemidiaphragm. in the increased right subphrenic space or intestinal hyper- mobility. These factors may be classified as congenital or ac- The pulmonary gas exchange at rest was preserved, and 1, 5, 7–9 quired (Table 1) , diaphragmatic, intestinal, hepatic, and bronchoobstruction was verified on spirometry. Standard 4 others (Table 2) . laboratory test findings were within normal ranges. The bacte- riological sputum finding was normal as well. Computed Table 1 tomography (CT) of the chest excluded the presence of infil- Congenital and acquired predisposing factors for Chilaiditi's trative lesions in the pulmonary parenchyma, verified bilateral sign and syndrome 1, 5, 7–9 bronchiectases, bilateral excrescences in the basal pleura, de- Predisposing factors generative spinal lesions, and the Chilaiditi's sign (Figure 2). Congenital Acquired Absence of: Chronic obstipation - suspensory ligament Fecal impaction (ligamentum suspensorium Cirrhosis with liver atrophy duodeni) Ascites - falciform ligament Aerophagia (ligamentum falciforme Obesity hepatis) Right hemidiaphragm Malposition of abdominal paralysis organs COPD Dolichocolon Multiple pregnancies Right hemidiaphragm Colonoscopy paralysis Pregnancy Laxitas (weak connective tissue) COPD – chronic obstructive pulmonary disease. The diagnosis is established on the basis of the chest X- Fig. 2 – Computed tomography of the chest verified the ray finding presented with the following three features 5, 7: Chilaiditi's sign (arrow). elevation of the right hemidiaphragm; a crescent lucency be- Zvezdin B, et al. Vojnosanit Pregl 2016; 73(3): 277–279. Vol. 73, No. 3 VOJNOSANITETSKI PREGLED Page 279 low the diaphragm on the right (the air-distended intestine – cedures, including percutaneous liver biopsy, pleural puncture, “pseudoperitoneum”); shadow of the upper liver line below and colonoscopy 4, 5. the right hemidiaphragm. Chilaiditi's syndrome is a rare condition manifested by diverse gastrointestinal symptoms, and a radiologically veri- Table 2 fied Chilaiditi's sign. It occurs very rarely, in elderly males Diaphragmative, hepatic, and intestinal predisposing factors 4 four times as frequently as in elderly females, and the cases for Chilaiditi's sign and syndrome in children have also been reported 4. It is manifested by the Predisposing factors symptoms differing in intensity and frequency – abdominal Diaphragmatic Elevated right hemidiaphragm due to: pains,
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