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Home , Chilaiditi syndrome

Case Report

Chilaiditi's syndrome - hepatodiaphragmatic interposition of the colon

Aamir A Hamza, MD*, Amal A Mohammed, MBBS**, Mohayad AE Bakhiet, MD***

Associate Professor, Department of Surgery, College of Medicine & Health Sciences, University of Bahri, Sudan*, Omdurman Teaching Hospital, Khartoum, Sudan**, Department of Surgery, Faculty of Medicine, University of Khartoum***

متالزمة شايالدتى “”Chilaiditi - مداخلة القولون بين الكبد و الحجاب الحاجز

عامر عبدﷲ حمزة *، أمل عبدﷲ محمد **، مھيد احمد الحاج بخيت ** قسم الجراحة، كلية الطب والعلوم الصحية، جامعة بحري * أم درمان المستشفى التعليمي، الخرطوم، السودان **

ملخص متالزمة Chilaiditi ھى حالة سريرية نادرة، التي يمكن الخلط بينھا وبين البطن الجراحية الحادة. نحن ھنا نقدم تقرير حالة نموذجية لذكر سودانى عمره 70عاما تم تأكيده أشعاعيا وعالجه تحفظيا. تم إضافة استعراض موجز لألدب. الكلمات الدالة: متالزمة Chilaiditi، وعالمة Chilaiditi، ومداخلة القولون بين الكبد و الحجاب الحاجز.

Abstract Chilaiditi’s syndrome is rare clinical The aetiological factors of the condition can condition, which might be confused with acute be intestinal, diaphragmatic, and hepatic or surgical . We report herein a typical enlarge thoracic outlet. The incidence of this case of a 70-year-old Sudanese male anomaly in the general population ranges from confirmed radiologically and treated 0.025% to 0.28%, with increase in China to conservatively. A brief review of the literature 0.38%. It increases with age and is much was added. lower during childhood. HDI is one of the Keywords: Chilaiditi's syndrome, chilaiditi's differential diagnoses of sign, hepatodiaphragmatic interposition of the as a perforated viscus or subdiaphragmatic colon. abscess(1, 2). Introduction Case report Chiliaditi’s syndrome is the symptomatic A 70-year-old male was referred to our hepatodiaphragmatic interposition of the colon surgical casualty at Omdurman Teaching or small intestines (HDI), whereas chilaiditi Hospital, with vague generalized abdominal sign is generally considered an incidental and pain, upper gastrointestinal upset for 10 days. asymptomatic radiographic findings. This He then developed bouts of abdominal syndrome was described for the first time by distension. There were no symptoms the radiologist Demetrius Chiliaditi in 1910. suggestive of any other system involvement, no past history of a similar attack or previous ______operation and no relevant medical, surgical or Corresponding author family history. The patient had no co- Aamir A Hamza morbidity. On physical examination he was Department of Surgery, dehydrated, pyretic and had generalized College of Medicine & Health Sciences, . The orifices were University of Bahari, Sudan intact. The abdomen was soft, hyper-resonant Email: [email protected] and no masses were felt. Bowel 209 Sudan Med J 2012 December;48(3)

Case Report Chilaiditi’s syndrome Aamir A Hamza sounds were not exaggerated. Digital rectal The patient was referred with ultrasound scan examination revealed no abnormality. Full showing significant dilated and distended blood count, urine analysis and random blood bowel loops, more evident, seen along the sugar were normal. His renal profile showed course of the colon and hepatic flexure, with the following: blood urea (28mg/dl), serum query abnormal interposition of the transverse creatinine (0.8mg/dl) serum K+ (2.3meq/l) colon anterior to the (chiliaditi’s and serum Na+ (130meq/l). Erect chest X-ray syndrome). The other abdominal viscera showed elevated right hemidiaphragm with revealed no abnormalities). interposition between it and The patient was given intravenous fluids and the liver (Fig 1). potassium chloride to correct his dehydration and hypokalaemia, and he was kept fasted Fig 1: Posteroanterior chest X-ray, together with gastric decompression through showing right subphrenic air nasogastric tube. On his second day of admission, all his complaints and physical findings have completely disappeared with this conservative regimen. For this reason, the planned CT abdomen was deferred, and instead a follow-up chest X-ray was done, which revealed no evidence of subphrenic air. Discussion Chilaiditi’s sign is the asymptomatic interposition of the intestine, usually a portion of the hepatic flexure of the colon, between the liver and diaphragm, whereas chilaiditi’s The supine and erect abdominal X-ray showed syndrome refers to clinical symptoms such as distended loops of the small bowel, but abdominal distension, pain or anorexia without evidence of air fluid levels (Fig 2). developing from this phenomenon(3). There are

Fig 2: Supine abdominal X-ray, several cases reported in literature that showing distended loops of bowel describe the associations between chilaiditi’s syndrome and one of the following: colonic , especially the “transverse colon, an angina-like pain(4) and large secondary to a malignant sigmoid stenosis. Other associations include severe hypokalaemia from renal tubular acidosis(5) and in a patient suffering from progressive systemic sclerosis. Severe dilatations of the intestine, pneumatosis cystoids intestinalis and abdominal free air, were reported as well with HDI. carcinomatosa due to cancer of pancreatic tail were also being reported(6). The syndrome might be complicated by caecal perforation(7). The aetiological factors of HDI can either be intestinal: malrotation, redundant loop with

210 Sudan Med J 2012 December;48(3)

Case Report Chilaiditi’s syndrome Aamir A Hamza long mesentery, diaphragmatic: phrenic nerve bowel loops with no obstructive lesion. In our injury, hepatic: small or atrophic liver case the CT scan was not done as these , enlarge thoracic outlet: emphysema features were clearly seen on the plain X-ray or pregnancy, elevated intra-abdominal on admission and totally disappeared on the pressure(2,3,8). Our patient likely to have second day(6,9). intestinal factor with the possibility of is an emergent condition, and redundant loop with long mesentery, as no it is mandatory to evaluate and treat without evidence of malrotation was found delay. Pneumoperitoneum is usually attributed radiologically as well, and the other to perforation of the . aetiological factors were ruled out clinically. Approximately 10% of pneumoperitoneum is Three types of HDI were identified according not associated with hollow organ perforation. to the anatomic relations of the liver to the There are many imitators of adjacent organs: pneumoperitoneum including subphrenic • The transverse colon protrudes into the right abscess, colon volvulus, morgagni hernia is an anterior subphrenic space. uncommon that • The transverse colon protrudes into the right generally requires surgery. This can be posterior subphrenic space. confused with chilaiditi’s syndrome. • The third type when, the stomach and colon Abdominal computed tomography in the latter protrude into the right extra-peritoneal case can reveal no bowel interposition(10). subphrenic space(8). Radiologically our Conservative treatment is the gold standard patient had the second type of HDI, which policy in the form of bed rest, nasogastric was proved by his chest X-ray on admission. decompression, intravenous fluid, enema and Air under the diaphragm seen on plain laxatives(11). Our patient responded radiograph usually signifies a perforated dramatically to this approach in less than 24 viscus, which represents a surgical emergency. hours. Surgical treatment may be required in Pneumoperitoneum from such condition cases of persistent pain, refractory , should be differentiated from the colonic volvulus or bowel ischemia(9). pseudopneumoperitoneum of chilaiditi’s Colopexy of the transverse colon to the syndrome, to allow proper diagnosis and falciform ligament and anterior abdominal treatment. Identification of the haustral folds wall had been done to a child who failed to or plicaecirculares between the liver and improve on conservative measures (this might diaphragm is crucial to avoid a be done laparoscopically). Colectomy for misdiagnosis(9). A posteroanterior and a lateral sigmoid volvulous is another option(12).The will show elevation of the patient was seen one month later in the right hemidiaphragm and interposition of the outpatient clinic without further complaints. transverse colon between the diaphragm and In conclusion, chilaiditi’s sign should be kept the liver, with downward displacement of the in the minds of patients presenting with air liver. This was similar to the radiological under the diaphragm and distended bowel finding of our patient. When doubt exists, loops. Recognizing bowel haustrations in the contrast-enhanced computed tomography hepatodiaphragmatic space confirms the should be done, and it will show the diagnosis and avoids unnecessary surgery. hepatodiaphragmatic interposition of the Surgical management of these patients ascending colon, with diffuse dilatation of depends on the underlying aetiology.

211 Sudan Med J 2012 December;48(3)

Case Report Chilaiditi’s syndrome Aamir A Hamza

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