THE CLINICAL PICTURE HIROKI MATSUURA, MD HIDENORI HATA, MD, PhD Department of General Internal Medicine, Department of Gastroenterology, Mitoyo General Hospital, Kagawa, Japan Mitoyo General Hospital, Kagawa, Japan

Gas under the right diaphragm

Figure 2. The Chilaiditi sign on computed tomog- Figure 1. Radiography of the chest with the patient raphy, with volvulus of the cecum between the standing showed gas under the right diaphragm diaphragm and liver and a closed-loop obstruction (arrows). (arrows).

66-year-old man presented to the hos- The patient was successfully treated with A pital with 3 days of nausea, vomiting, and urgent right hemicolectomy. abdominal pain. He had come to the emer- gency department several times during this ■■ THE CHILAIDITI SIGN AND SYNDROME period, but the cause of his symptoms had not been determined. The Chilaiditi sign is an infrequent anomaly He had no significant medical history and found incidentally on chest or abdominal ra- no previous hospital admissions. He had never diography as a colonic interposition between 1 undergone colonoscopy and had never taken the liver and right hemidiaphragm. It is often anticoagulant agents, steroids, laxatives, or asymptomatic but is sometimes accompanied nonsteroidal anti-inflammatory drugs. by nausea, vomiting, abdominal pain, and His abdomen was mildly tender without constipation, ie, Chilaiditi syndrome. guarding or rigidity. The standing chest radio- Generally, after conservative treatment graph showed gas under the right diaphragm with fasting and pain control, symptoms may (Figure 1), and computed tomography (CT) subside and follow-up should be sufficient. revealed the Chilaiditi sign, with volvulus of However, nasogastric decompression and lax- the cecum between the diaphragm and liver atives are occasionally needed and are often and a closed-loop obstruction (Figure 2). effective in patients with Chilaiditi syndrome. doi:10.3949/ccjm.85a.16139 Urgent abdominal surgery is indicated for pa-

98 CLEVELAND CLINIC JOURNAL OF MEDICINE VOLUME 85 • NUMBER 2 FEBRUARY 2018 Downloaded from www.ccjm.org on September 29, 2021. For personal use only. All other uses require permission. CHILAIDITI SYNDROME

tients with symptoms of volvulus of the colon, gallstone ileus, and pneumatosis cystoides stomach, or small intestine.2 intestinalis. The incidence rate of the Chi- laiditi sign detected by radiography is between ■ DISTINGUISHING CHARACTERISTICS 0.025% and 0.28%.3 The Chilaiditi sign is often confused with pneumoperitoneum, which usually requires ■ PREDISPOSING FACTORS urgent abdominal surgery. But the presence The cause of the Chilaiditi sign remains un- of haustration or valvulae conniventes (folds known. Predisposing factors can be catego- in the small bowel mucosa) in the hepatodia- rized as diaphragmatic (diaphragmatic thin- phragmatic space helps distinguish between ning, phrenic nerve injury, expanded thoracic intraluminal gas and free air. If the patient cavity), intestinal (megacolon, increased in- presents with abdominal pain without signs of tra-abdominal pressure), and hepatic (hepatic peritonitis, and if imaging indicates the Chi- atrophy, cirrhosis, ascites). laiditi sign, then supplementary imaging (eg, In healthy people, Chilaiditi syndrome is decubitus radiography, chest CT, abdominal usually attributed to a congenital abnormal CT) is recommended to make the definitive lengthening of the colon or to undue loose- diagnosis and to avoid unnecessary surgery. ness of ligaments of the colon and liver. Gas under the diaphragm on standing Recognizing the Chilaiditi sign is particu- chest radiography without signs of peritonitis larly important in patients scheduled to under- may also be seen after laparotomy and after go a percutaneous transhepatic procedure or scuba diving as well as in cases of biliary en- colonoscopic examination, as these procedures teric fistula, incompetent sphincter of Oddi, increase the risk of perforation. ■ ■ REFERENCES 1. Chilaiditi D. Zur Frage der Hepatoptose und Ptose im 3. Orangio GR, Fazio VW, Winkelman E, McGonagle BA. allegemeinen im Anschluss an drei Fälle von temporärer, The Chilaiditi syndrome and associated volvulus of the Predisposing partieller Leberverlagerung. Fortschritte auf dem transverse colon. An indication for surgical therapy. Dis Gebiete der Röntgenstrahlen 1910; 16:173–208. Colon Rectum 1986; 29:653-656. factors are 2. Williams A, Cox R, Palaniappan B, Woodward A. Chi- laiditi’s syndrome associated with colonic volvulus and ADDRESS: Hiroki Matsuura, MD, Mitoyo General Hospital, categorized as intestinal malrotation—a rare case. Int J Surg Case Rep 708, Himehama, Toyohama-cho, Kanonji-city, Kagawa, 769- 2014; 5:335–338. 1695 Japan; [email protected] diaphragmatic, intestinal, and hepatic

100 CLEVELAND CLINIC JOURNAL OF MEDICINE VOLUME 85 • NUMBER 2 FEBRUARY 2018 Downloaded from www.ccjm.org on September 29, 2021. For personal use only. All other uses require permission. CORRECTIONS

Gas under the right diagphragm FEBRUARY 2018

In the article “Gas under the right diaphragm” (Mat- suura H, Hata H. Cleve Clin J Med 2018; 85[2]:98– 100), Figure 2 appeared upside down. It should have appeared as follows:

Figure 2. The Chilaiditi sign on computed tomog- raphy, with volvulus of the cecum between the diaphragm and liver and a closed-loop obstruction (arrows). The correction has been made to the online version at www.ccjm.org. Physical examination in dyspnea DECEMBER 2017

On page 949 of the article “Diagnostic value of the physical examination in patients with dyspnea” (Shel- lenberger RA, Balakrishnan B, Avula S, Ebel A, Shaik S. Cleve Clin J Med 2017; 84[12]:943–950), the terms “abdominojugular refl ex” and “hepatojugular refl ex” should have been “abdominojugular refl ux” and “hepa- tojugular refl ux.” This error also occurred in Table 5 on that page. The correction has been made to the online version at www.ccjm.org.

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