Beware of Chilaiditi sign!!

A 41-year-old male with a history of Down's syndrome, seizure disorder, renal calculi, and chronic respiratory failure was admitted for complicated urinary tract infection. Chest X-ray (Fig. 1) showed elevated right hemidiaphragm. CT abdomen (red arrows Figs. 2 and 3) demonstrated interposition of colon between right hemidiaphragm and liver (Chilaiditi sign) as well as gallstones. Chilaiditi sign is an incidental radiological finding described by Greek radiologist Demetrius Chilaiditi in1910 (1). It is characterized by interposition of the colon between the right hemidiaphragm and liver. Incidence is 0.1–1% and most patients are asymptomatic (2). It is called Chilaiditi syndrome when this finding is associated with symptoms such as abdominal pain, distension, vomiting, anorexia, and constipation (3). Chilaiditi sign is probably due to lax suspensory ligament of colon or liver causing excessive mobility of colon. Diagnosis is suspected by chest X-ray and confirmed with CT scan. Surgery is reserved only for patients with resistant symptoms. It is important to know this entity because it can be mistaken for bowel perforation and can lead to unnecessary surgical intervention.

Fig. 1

X-ray of chest showing air under the elevated hemidiaphragm.

Fig. 2

Coronal CT scan image shows the interposition of the colon between right hemidiaphragm and the liver (red arrows).

Fig. 3

Transverse CT scan image shows the interposition of the colon between right hemidiaphragm and the liver (red arrows).