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clearance of bile duct stones resistant to Postgrad Med J: first published as 10.1136/pmj.79.929.181 on 1 March 2003. Downloaded from SELF ASSESSMENT ANSWERS endoscopic extraction. Gastrointest Endosc 2001;53:27–32. 2 Kratzer W, Mason R, Grammer S, et al. Treatment options for session.367The success rate of this procedure, Difficult bile duct stone recurrence after with complete clearance of the common bile endoscopy and exracorporeal shock wave common bile duct stones duct is between 80% and 90%.1–3 6 lithotripsy. Hepatogastroenterology The main complication is cholangitis (1%– 1998;45:910–6. Q1: What are the treatment options 8%) and this is reduced by use of prophylactic 3 White DM, Correa RJ, Gibbons RP, et al. for this patient? 16 Exracorporeal shock wave lithotripsy for bile antibiotics. Procedure related mortality has 175 – These are summarised in fig 1. Endoscopic duct caculi. Am J Surg 1998; :10 3. not been reported. 4 Gilchrist A, Ross B, Thomas WE. extraction of common bile duct stones after Extracorporeal shockwave lithotripsy for spincterotomy and mechanical lithotripsy has Q2: What does the post-treatment common bile duct stones. Br J Surg a success rate of up to 95% and is considered ERCP film (fig1 in questions; see p 1997;84:29–32. the treatment of choice.12The reason for fail- 178) show? 5 Janssen J, Johanns W, Weickert U, et al. ure in this case was the large size of the bile At repeat ERCP the pigtail stent was removed Long term results after successful extracorporeal gallstone lithotripsy. Scand J duct calculus. Other reasons include bile duct and the cholangiogram shows no evidence of strictures, unusual anatomy, and calculi be- Gastroenterol 2001;36:314–7. calculi with satisfactory drainage from the Ellis RD yond reach of the wire basket.1–3 6 , Jenkins AP, Thompson RP, et al. common bile duct. Clearance of refractory bile duct stones with Traditionally such patients have been re- Spontaneous passage of calculi occurs in up exrtacorporeal shockwave lithotripsy. Gut ferred for surgical exploration of the common to 10% of patients, with 80% requiring removal 2000;47:728–31. bile duct but this procedure is not without of stone fragments during repeat ERCP.1 Al- 7 Lomanto D, Fiocca F, Nardovino M, et al. risk, particularly in elderly patients or those ESWL experience in the therapy of difficult 4 though recurrence of bile duct calculi is with major medical comorbidities. estimated at 14% after one year, most of these bile duct stones. Dig Dis Sci 1996;41:2397–403. Extracorporeal shock wave lithotripsy are amenable to endoscopic treatment.2 (ESWL) was investigated initially for treatment ESWL is an effective non-invasive treat- of gallbladder stones, but a high stone recur- ment modality that can be performed safely An unusual cause of rence rate has limited its use in this condition. 5 on an outpatient basis, without use of general In recent years high energy ESWL has been anaesthesia. For this reason it is a useful persistent vomiting used with more promising results in high risk treatment option in patients with difficult Q1: What abnormality is shown on the patients with common bile duct stones. common bile duct calculi who are considered In this case, given the patient’s age and to be poor candidates for surgery. barium meal (see p 178)? comorbidities it was decided that this was the An abnormal filling defect in close association treatment of choice. Biliary drainage was Final diagnosis with a thin C-shaped radio-opaque strip can achieved during initial ERCP using a pigtail Extracorporeal shock wave lithotripsy as a be seen in the gastric remnant (grey arrow). stent. treatment option for common bile duct Radio-opaque clips can also be seen around The patient then underwent one session of calculi. the cardia (white arrow). These appearances high energy ESWL, during which the calculus are in keeping with an Angelchik prosthesis was targeted by ultrasonography.12 Studies References which has become detached and eroded into have shown that between 20% and 50% of 1 Sackmann M, Holl J, Sauter GH, et al. the stomach. patients will require more than one treatment Extracorporeal shock wave lithotripsy for Q2: What are the options for dealing with this complication? Gastroscopy should be performed not only to confirm the diagnosis but also in an attempt to remove the prosthesis endoscopically.1 At http://pmj.bmj.com/ gastroscopy the stomach mucosa appeared normal and the silicon prosthesis, although covered with debris, was easily visualised. However, despite several attempts, it was not possible to retrieve the prosthesis endoscopi- cally. The only other option was to remove the prosthesis surgically and this was performed in this case by carrying out a laparotomy and gastrotomy. The patient made an uncompli- on September 27, 2021 by guest. Protected copyright. cated recovery and was free of symptoms at review three months later. Q3: What other complications have been reported after insertion of this prosthesis? The Angelchik prosthesis is no longer widely used because of the high incidence of compli- cations. Intractable dysphagia was common and often required removal of the prosthesis. Free extraluminal migration into the abdomi- nal cavity can occur. The prosthesis usually comes to rest in the pelvis and is usually manifested by chronic lower abdominal pain or urinary symptoms. Migration into the mediastium and distal slippage has also been reported. Erosion of the prosthesis into the oesophagus can lead to abscess formation and intraluminal erosion may even progress to cause small bowel obstruction. Discussion In 1979, Angelchik and Cohen reported a series of 46 patients who had reflux oesophagitis Figure 1 Treatment options for common bile duct stones (CBD, common bile duct; ERCP, treated surgically with the insertion of an endoscopic retrograde cholangiopancreatography; ESWL, extracorporeal shockwave incomplete “doughnut” shaped ring of silicon lithotripsy). around the gastro-oesophageal junction: the

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Angelchik prosthesis. The C-shaped ring was relieved by rest. The pain is usually localised to Final diagnosis Postgrad Med J: first published as 10.1136/pmj.79.929.181 on 1 March 2003. Downloaded from tied around the lower oesophagus with Dacron the groin, inner thigh, or knee region. On Legg-Calvé-Perthes disease. straps. Insertion of this prosthesis was quick, examination, these children will have a simple to perform, and standardised and it was positive Trendelenburg test and have limited References hoped that it would become superior to the abduction and difficulty medially rotating 1 Pokharel RK. Children with Legg-Perthes other surgical antireflux procedures available their affected leg. Often, they also have trouble diseases. Clin Orthop 1999;363:268–9. at the time which were all technically difficult, with hip motion. With disease progression, 2 Leet AI. Evaluation of the acutely limping time consuming, and had variable results necrosis of the femoral head leads to further child. Am Fam Physician 2000;64:1011–8. Hubbard AM which were operator dependent.2 degeneration and immobilisation of the hip, 3 . Imaging of pediatric hip which can then progress to disuse atrophy of disorders. Radiol Clin North Am The early short term results for the prosthe- 39 – the buttocks, thigh, and calf muscles.1 2001; :721 32. sis were promising, and objective and subjec- 4 Roy DR. Current concepts in tive outcome measures were similar to other Q2: What are alternative differential Legg-Calve-Perthes disease. Pediatr Ann accepted surgical antireflux procedures.3 1999;28:748–52. However the initial enthusiasm has been diagnoses in a child with a limp? tempered with experience and when more The differential diagnosis list for a child with long term results were analysed up to 20% of a limp is quite extensive and can include vari- Middle aged man with prostheses had to be removed for intractable ous hormonal, metabolic, orthopaedic, and groin pain dysphagia and there were other reports of genetic causes. Frequent causes of limp also vary by age group. In the 4–11 year old age significant problems due to migration and Q1: What abnormality is shown and 45 group, the most common causes of a limping erosion of the prosthesis. what is the diagnosis? The prosthesis has a tantulum radio- gait are: septic arthritis, osteomyelitis, tarsal coalition, transient monoarticular synovitis, We can see a contrast filled oblong sac on the opaque marker encircling its periphery and left inguinal region (fig 1; see p 179). This is radio-opaque clips were frequently used to juvenile rheumatoid arthritis, LCP, slipped capital femoral epiphysis, and neoplasias such herniation of the bladder in forming the wall reinforce the knot in the tied Dacron straps 12 as osteoid osteomas or osteochondromas.2 of the direct inguinal hernia. making it possible to identify the prosthesis Many of these common causes can be on radiological images as seen in this case. diagnosed by laboratory evaluation such as Q2: How do you manage this The continued use of the Angelchik pros- erythrocyte sedimentation rate for transient problem? thesis was abandoned in most centres over 10 monoarticular synovitis, rheumatoid factor The management of this condition is in two years ago but at least 25 000 have been and antinuclear antibody testing for juvenile parts: inserted worldwide. In this case erosion rheumatoid arthritis, and presence of a febrile (A) Repair of the inguinal hernia, which is occurred 14 years after insertion, longer than course for septic arthritis or osteomyelitis. the main cause of the pain, using a form of any other case reported. The presentation of wire mesh to reinforce the posterior wall of new gastrointestinal symptoms should still Discussion the inguinal canal to prevent recurrence of the today arouse suspicion in a patient known to Epidemiologically, LCP disease has been shown hernia.1 have an Angelchik prosthesis. to be associated with a myriad of external fac- (B) Repair of the bladder diverticulum by tors such as lower socioeconomic group, ad- Final diagnosis open diverticulectomy or laparoscopic vanced maternal age, later born children, short diverticulectomy.34 Eroded Angelchik prosthesis. stature, low birth weight, delayed bone age, and breech birth. LCP also demonstrates a Q3: What complications may arise References higher incidence in Asian and eastern Euro- during the management of such 1 Souka H, Karanjia ND. Endoscopic removal pean populations and a decreased incidence in patients? of an Angelchik prosthesis after migration African- Americans and native Americans. through the gastro-oesophageal junction. If the surgeon is unaware of the possibility of Trauma can be related to the onset of symp- Endoscopy 1995;27:464. herniated bladder forming hernial sac, the toms but is not implicated as a direct cause. 2 Angelchik JP, Cohen R. A new surgical bladder may be inadvertently damaged dur- procedure for the treatment of LCP disease is diagnosed and staged by

ing the hernia repair. http://pmj.bmj.com/ gastroesophageal reflux and hiatal hernia. radiography. Radiographs should be taken in Surg Gynecol Obstet 1979;148:246–8. the anteroposterior and frog-leg lateral posi- Discussion 3 Gear MW, Gillison EW, Dowling BL. tion and are used to determine the progressive This is a rare condition where there is hernia- Randomized prospective trial of the Angelchik stage of the disease. The four classification anti-reflux prosthesis. Br J Surg tion of the bladder in forming the wall of the stages for LCP disease are (1) initial, (2) frag- 1 1984;71:681–3. direct inguinal hernia, and only about 100 mentation, (3) reossification, and (4) 56 4 Maxwell-Armstrong CA, Steele RJ, Amar cases have been reported world wide. healing.3 Radiographic findings can also be SS, et al. Long-term results of the Angelchik The treatment of this condition depends on used to determine prognosis. Poor prognosis is prosthesis for gastro-oesophageal reflux. Br J the diagnosis and divided into two parts: generally associated with the degree of Surg 1997;84:862–4. repair of the hernia and repair of the deformity of the femoral head and acetabu- on September 27, 2021 by guest. Protected copyright. 5 Varshney MSS, Kelly JJ, Branagan G, et al. diverticulum (see answer to question 2 Angelchik prosthesis revisited. World J Surg lum, female sex, and age of onset after 8 years above). 2002;26:129–33. of age. Definitive diagnosis of LCP must be done by technetium bone scan or magnetic Final diagnosis resonance imaging to show the avascular Herniation of the bladder. A limping 6 year old child necrosis of the femoral head and subsequent with no history of illness or acetabulum-femoral deformity. References Therapy for LCP disease depends on the 1 Schewe J, Brands EH, Pannek J. The inguinal trauma child and severity of the illness, active bladder diverticulum—a rare differential treatment is not required for all children. The Q1: What is the likely diagnosis and diagnosis of hernias. Int Urol Nephrol main treatment, when indicated, is contain- 2000;32:255–6. how does it typically present? ment of the femoral head within the acetabu- 2 Buchholz NP, Biyabani R, Talati J. Bladder Legg-Calvé-Perthes (LCP) disease, also lum by casting, immobilisation, or more inva- diverticulum as an unusual content of a known as idiopathic avascular necrosis of the sive surgical methods. In the majority of femoral hernia. Br J Urol 1998;82:457–8. Fukatsu A proximal femoral epiphysis, is one of the more children, LCP disease is a local, self healing 3 , Okamura K, Nishimura T, et al. insidious causes of a limp in the paediatric Laparoscopic extraperitoneal bladder disorder. The acetabulum undergoes bony diverticulectomy—an initial case report. population. It commonly presents between remodelling with subsequent improvement in Nippon Hinyokika Gakkai Zasshi the ages of 5 and 7, although it has been femoral head deformities. The long term 2001;92:636–9. reported in children ranging from the ages of prognosis is directly related to the onset of 4 Okamura K, Watanabe H, Iwasaki A, et al. 2 to 16. Although its aetiology remains symptoms and degree of residual femoral Closure of mouth of bladder diverticulum via unclear, it is three times more common in head deformity and results in an increased endoscopic transvesical-transurethral boys and has been shown to be associated incidence of degenerative osteoarthritis in approach. J Endourol 1999;13:123–6 with protein C and protein S deficiencies as adulthood. It was recently shown that up to 5 Gearhart JP, Jeffs RD. Campbell’s urology. well as various other thrombophilias. 80% of LCP disease patients who underwent 6th Ed. Philadelphia: W B Saunders, 1992;2:1814–15. Clinically, LCP disease presents with a containment, remained active, pain-free, with 6 Mann CV, Russell RCG, William NS. Bailey slowly developing and gradually worsening a good range of motion up to 40 years after and Loves short practice of surgery. 22nd Ed. limp, that may or may not be painful. Associ- onset of symptoms, regardless of radiographic London: Chapman and Hall Medical, 1995: ated pain is usually activity related and appearance.4 955–6.

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An elderly man with chest intestinal obstruction, subdiaphragmatic ap- Postgrad Med J: first published as 10.1136/pmj.79.929.181 on 1 March 2003. Downloaded from pendicitis) appropriate surgical intervention Box 1: Factors predisposing to pain, shortness of breath, is required. In our patient, who was treated intestinal hepatodiaphragmatic conservatively, the symptoms completely dis- interposition and constipation appeared after he opened his bowels with no recurrence or complications on follow up (for Q1: What do the chest radiographs 1. Anatomical show? two months) since treatment of constipation started. • Congenital elongation, malrotation, or The upright posteroanterior and lateral films malfixation of the bowel. (see p 180) show a marked elevation of the Discussion • Redundant bowel with a long mesen- right hemidiphragm with distended loops of A temporary or permanent hepatodiaphrag- tery. bowel interposed between the liver and right matic interposition of the colon, small intes- • Congenital or acquired laxity of hepatic abdominal wall. Haustration identifies the tine (rare), or stomach (exceptionally rare) is suspensory ligaments. large bowel, distinguishing colonic hepatodia- an uncommon and usually asymptomatic • - phragmatic interposition from subphrenic process. However, it can cause serious compli- Reduction of liver volume (lobar agen pneumoperitoneum or abscess. The lung cations and be a potential source of misdiag- esis, atrophic cirrhosis). fields and pleural spaces are clear. Note the nosis for a variety of intrathoracic and • Lower thoracic outlet enlargement with normal heart size and median sternotomy intra-abdominal disorders. high abdominothoracic pressure wires. Interestingly, the hepatodiaphragmatic The condition was named after Viennese gradient (pregnancy, obstructive airway interposition of the right colon had not been radiologist Demetrius Chilaiditi who in 1911 disease, emphysema, scoliosis, ascites). seen on films taken five and seven years reported three asymptomatic cases with tem- • Adhesions and mechanical obstruction. previously, but persisted after complete reso- porary hepatodiaphragmatic interposition of • Obesity. lution of the symptoms and was still present the colon and described their anatomoradio- on follow up two weeks later. The computed graphic aspects. The condition was first 2. Functional tomogram confirmed the hepatodiaphrag- described by Cantini in 1865, and Beclere in • Increased intestinal mobility. matic interposition of the colon and did not 1899 presented the necropsy and roentgeno- • Longstanding constipation (due to im- show any signs of pulmonary embolism. logical findings in a patient thought to have a mobilisation, diet, medications, etc). 12 subdiaphragmatic abscess. It has been pro- • Gaseous distention of the intestine Q2: What important physical sign may posed to use the term “Chilaiditi’s sign” in (meteorism). asymptomatic patients and the term “Chi- have been missed? • Diaphragm paralysis (centrally medi- Absent liver dullness may be a useful diagnos- laiditi’s syndrome” in symptomatic 34 ated or due to phrenic nerve injury). tic clue pointing to hepatodiaphragmatic patients. • Aerophagia. interposition. In Western countries the condition is uncommon and is found in 0.02% to 0.2% of Q3: What is the differential diagnosis? routine chest radiographs with a male to 156 The differential diagnosis must include a female ratio of 4:1. In some reports the number of cardiac and non-cardiac causes of incidence is even lower with only 0.002% (one anterior and superior to the right lobe of the of 50 000 adults7) or 0.000003% (three of liver (as in the described case). Hepatodia- chest pain and breathlessness. The initial 8 approach would be to rule out life threatening 11 378 000 ). Importantly, an increase in phragmatic interposition in the posterior sub- causes such as myocardial ischaemia and pul- prevalence of hepatodiaphragmatic interposi- phrenic space is much rarer. A case of monary embolism as well as acute pneumo- tion has been recorded in patients above 65 combined anterior and posterior types of years of age: from 0.02% to 0.2% in men and colon displacement has been reported.11 nia. In this patient the diagnostic difficulty 5 was compounded by the history of coronary from 0.006% to 0.02% in women. In one Only a minority of patients with intestinal study the prevalence in the geriatric popula- hepatodiaphragmatic interposition have artery disease and high risk of pulmonary 9 embolism (postoperative state and malig- tion was found to be 1%. In 135 persons with symptoms. These range from non-specific nancy). The pain occurred on walking (char- learning disabilities in New York, the inci- gastrointestinal symptoms such as nausea, http://pmj.bmj.com/ dence was 8.8%, or 63 times that in general anorexia, vomiting, flatulence, and constipa- acteristic for angina), was intensified by 1 inspiration (mimicking pleuritic pain typical population. A high incidence of hepatodia- tion to signs of pseudo-obstruction and rarely for pulmonary infarction), and was associated phragmatic interposition was observed in to life threatening complications like volvulus with shortness of breath and hypoxia. How- Iran: 0.22% in the normal population, 2% in or intestinal obstruction. The condition may ever, the pain lasted from 30 minutes to two women near term pregnancy, 2.7% in patients rarely present with central chest pain, cardiac with chronic lung disease, and 22% in patients arrhythmias, or respiratory distress.7 Symp- hours, was not associated with new ECG 10 changes nor elevation of cardiac enzymes, it with postnecrotic cirrhosis. toms probably occur only when the intestine responded to bed rest (but not to nitrates), The normal anatomy and physiology of the is distended or obstructed. Because the and a computed tomographic pulmonary intestine, liver, and diaphragm usually pre- accumulated gas naturally ascends the pa- on September 27, 2021 by guest. Protected copyright. angiogram revealed no embolism. Absence of vent hepatodiaphragmatic interposition. The tients usually become symptomatic in a pathophysiology is thought to be multifacto- sitting position or standing upright while bed fever, productive cough, sputum, and the 1 chest radiograph findings tend to exclude rial and includes an enlarged subphrenic rest diminishes the symptoms. Our case is pneumonia. The patient became asympto- space, congenital and/or acquired elongation, unusual in that the patient developed uncom- matic when constipation was successfully malrotation or malfixation of the intestine mon symptoms of chest pain and breathless- treated with enemas, stool softeners, and with increased mobility, laxity of the hepatic ness (without gastrointestinal symptoms laxatives. However, to verify that colonic suspensory ligaments, reduction of liver vol- apart from constipation). After complete hepatodiaphragmatic interposition is the only ume, and weakness (hyper-relaxation) of the resolution of clinical symptoms, in many cases diaphragm (due to defective innervation, the radiological picture of intestinal hepato- cause of angina-like pain, other investigations 1 may be needed to exclude coronary ischae- either centrally or peripherally mediated). diaphragmatic interposition remained un- mia. Chilaiditi emphasised hepatic mobility as the changed (as in our patient), indicating the primary pathophysiological cause of hepato- importance of colonic distention in the Q4: What were the predisposing diaphragmatic interposition, while others pathophysiology of the syndrome. postulated that a redundant colon with A wide range of coexisting disorders has factors to this condition? increased mobility is a prerequisite for devel- been reported including hiatus hernia, skel- Colonic elongation due to longstanding con- opment of this condition.1 Chronic constipa- etal abnormalities (spinal scoliosis), multiple stipation and probably adhesions (after prior tion, meteorism, aerophagia, adhesions, and congenital anomalies, obesity, pneumatosis stomach surgery) in an elderly patient (after mechanical obstructions are considered as cystoides intestinalis, melanosis coli, and lung hip fracture) with limited mobility taking a important factors.348 It is worth noting that cancer. Severe complications requiring sur- narcotic analgesic. chronic constipation is the most common gery such as sigmoid volvulus, incarceration cause of colonic elongation and redundancy, of colon, and suprahepatic appendicitis have Q5: What is the management of this leading to increased colonic mobility.3 Predis- been reported.5–7 12 13 condition? posing factors to intestinal hepatodiaphrag- On physical examination a marked de- Most patients are treated conservatively with matic interposition are shown in box 1. crease or even absent liver dullness and/or a bed rest, increased fluid intake, fibre supple- There are different anatomic types of intesti- “mass” in the right upper quadrant or mentation, laxatives, and enemas. In rare nal hepatodiaphragmatic interposition. Most mid-abdomen (displaced liver) may be diag- complicated cases (volvulus, internal hernias, frequently it occurs under the diaphragm nostically useful.

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Radiogically three signs are characteristic: 5 Torgersen J. Suprahepatic interposition of Postgrad Med J: first published as 10.1136/pmj.79.929.181 on 1 March 2003. Downloaded from (1) colon or small bowel interposed between Box 2: Learning points colon and volvulus of cecum. Am J Roentgenol the liver and the diaphragm (in symptomatic Radium Ther Nucl Med 1951;66:747–51. patients usually markedly distended), (2) • Intestinal hepatodiaphragmatic interpo- 6 Orangio GR, Fazio VW, Winkelman E, et al. elevated right hemidiaphragm, and (3) caudal The Chilaiditi syndrome and associated sition is a rare condition recognisable volvulus of the transverse colon. An indication and medial displacement of liver. However, by chest radiography and is most often when the bowel gas is lateral and posterior it for surgical therapy. Dis Colon Rectum asymptomatic (Chiliaditi’s sign). 1986;29:653–6. may not get above the liver or displace it; this • When symptomatic (Chilaiditi’s syn- 7 Risaliti A, De Anna D, Terrosu G, et al. is termed incomplete hepatodiaphragmatic Chilaiditi’s syndrome as a surgical and 14 interposition. drome) the interposition may present nonsurgical problem. Surg Gynecol Obstet The differential diagnosis of radiographic with a variety of clinical symptoms and 1993;176:55–8. findings include subdiaphragmatic abscess, signs, mainly gastrointestinal, but also 8 Melester T, Burt ME. Chilaiditi’s syndrome. pneumoperitoneum, cysts in pneumatosis with chest pain and dyspnoea. Report of three cases. JAMA 254 – intestinalis, hepatomegaly, posterior hepatic • Certain groups are predisposed to this 1985; :944 5. lesions, and retroperitoneal masses. In the 9 Walsh SD, Cruikshank JG. Chilaiditi condition (elderly persons with consti- first two of these conditions, which are syndrome. Age Ageing 1977;6:51–7. associated with elevation of the right hemidi- pation, the intellectually disabled, pa- 10 Vessal K, Borhanmanesh F. aphragm and subdiaphragmatic air collection, tients with chronic lung disease, emphy- Hepatodiaphragmatic interposition of the the haustral markings (usually best seen on sema, cirrhosis, and pregnant women). intestine (Chilaiditi’s syndrome). Clin Radiol 1976;27:113–6. lateral films) are absent. With pneumoperito- • In elderly patients the differential diag- 11 Oubenaissa A, Perrault LP, Ridoux G, et al. neum the free air is shifting (usually obvious nosis of chest pain and respiratory dis- Hepatodiaphragmatic interposition of the in the lateral decubitus view) and may be tress should include Chilaiditi’s syn- colon—an unusual case of combined anterior bilateral. In subdiaphragmatic abscess, the drome among other gastrointestinal and posterior types treated with an original air-fluid level is smaller and often associated operative technique: report of a case. Dis with basal atelectasis and pleural effusions. disorders. Colon Rectum 1999;42:278–80. Hepatodiaphragmatic interposition of the • The treatment is usually conservative 12 Fukuchi Y, Hirano A, Aoki T. Rare case of intestine may also be diagnosed with abdomi- (bed rest, increased fluid and fibre internal hernia with a new type of nal ultrasound.15 If doubt remains, contrast intake, laxatives, enemas), although hepatodiaphragmatic interposition of the enema, thoracoabdominal computed tomog- stomach and colon. Am J Gastroenterol rarely surgical intervention is needed 1989;84:1322–4. raphy or nuclear scintigraphy are recom- (volvulus, obstruction). 13 Isbister WH, Bellamy P. mended. Hepato-diaphragmatic interposition of the Chilaiditi’s syndrome may present with a intestine (Chilaiditi’s syndrome): a case report. wide range of symptoms and signs which Aust N Z J Surg 1991;61:462–4. could be misleading to the attending clinician. tial diagnosis of chest pain and dyspnoea, 14 Waldman I, Berlin L, Fong JK, Lascari A. The entity may mimic a number of cardiac, especially in elderly people, as well as in Chilaiditi’s syndrome—fact or fancy? JAMA respiratory, and other non-cardiac disorders. patients with intellectual disability, chronic 1966;198:1032–3. 15 Sato M, Ishida H, Konno K, et al. Chilaiditi The clinical differential diagnosis may be par- lung disease, or cirrhosis. ticularly difficult in elderly persons because of syndrome: sonographic findings. Abdom 25 – the frequent coexistence of two or more con- Final diagnosis Imaging 2000; :397 9. ditions contributing to the clinical picture (as 16 Tendil H. [Role of left colonic distension in the Colonic hepatodiaphragmatic interposition diagnosis of atypical precordial pain]. Coeur in the described case). Although in patients (Chilaiditi’s syndrome). Med Interne 1978;17:251–5. with chest pain, the differential diagnosis ini- 17 Brandt LJ. Managing GI disorders of aging: tially must include myocardial ischaemia, References noncardiac chest pain and rectal bleeding. pulmonary embolism, aortic dissection or 1 Lekkas CN, Lentino W. Symptom-producing Geriatrics 1986;41:20–4, 27, 30. pericarditis, other types of non-cardiac chest interposition of the colon. Clinical syndrome in 18 Schneidau A, Baron HJ, Rosin RD. Morgagni pain should also be considered. Constipation mentally deficient adults. JAMA revisited: a case of intermittent chest pain. Br J

and colonic distention as a cause of praecor- 1978;240:747–50. Radiol 1982;55:238–40. http://pmj.bmj.com/ dial pain,16–18 hypoxia, and respiratory 2 Haddad CJ, Lacle J. Chilaiditi’s syndrome. A 19 Milanese A, Schechter NL, Ganeshananthan distress19 20 has been described but infre- diagnostic challenge. Postgrad Med M. Constipation presenting as respiratory quently diagnosed. Constipation which is 1991;89:249–50, 252. distress. J Adolesc Health Care 7 – common in elderly people affecting a third of 3 Plorde JJ, Raker EJ. Transverse colon volvulus 1986; :255 8. 21 and associated Chilaiditi’s syndrome: case 20 Luder AS, Segal D, Saba N. Hypoxia and elderly women and a quarter of elderly men, report and literature review. Am J chest pain due to acute constipation: an is a significant predisposing factor for intesti- Gastroenterol 1996;91:2613–6. underdiagnosed condition? Pediatr Pulmonol nal hepatodiaphragmatic interposition. 4 Schubert SR. Chilaiditi’s syndrome: an 1998;26:222–3. This case emphasises the importance of unusual cause of chest or abdominal pain. 21 Schaefer DC, Cheskin LJ. Constipation in the

considering Chilaiditi’s syndrome in differen- Geriatrics 1998;53:85–8. elderly. Am Fam Physician 1998;58:907–14. on September 27, 2021 by guest. Protected copyright.

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