Man with chest discomfort.

CASE PRESENTATION

A 76‐year‐old man presented to the emergency department complaining of intermittent chest tightness during the preceding day that had resolved “after passing gas.” His physical examination was unremarkable, and his electrocardiogram (ECG) showed no acute ischemic changes. Standard posterior–anterior and lateral radiographs of the chest were obtained (Figures 1 and 2).

FIGURE 1

Posterior–anterior view of the chest showing interposition of a segment of the large colon between the liver and the diaphragm

FIGURE 2

Lateral view of the chest showing interposition of a segment of the large colon between the liver and the diaphragm

DIAGNOSIS

Chilaiditi syndrome

Chilaiditi sign describes the radiographic findings of interposition of a segment of large or small bowel between the liver and the diaphragm. Anatomic variations that lead to this condition include the absence or laxity of the suspensory ligaments of the transverse colon or falciform ligament. Chilaiditi sign is rare with an incidence of 0.025% to 0.28% and a male to female ratio of 4:1. The diagnosis of Chilaiditi sign is made based on the following radiologic findings: the right hemidiaphragm is elevated above the liver by the intestine, the interposed bowel segment is distended by air mimicking pseudopneumoperitoneum, and the superior margin of the liver is depressed below the level of the left hemidiaphragm. Chilaiditi sign may be misinterpreted as a diaphragmatic hernia or pneumoperitoneum, resulting in unnecessary surgical intervention. , The presence of plicae circulares or haustral markings under the diaphragm can help rule out free intraperitoneal air.

Chilaiditi sign is typically asymptomatic and requires no intervention. Chilaiditi syndrome is the result of complications from Chilaiditi sign, manifesting as abdominal pain, vomiting, or constipation, although there are reports of respiratory symptoms and chest pain. Complications of the syndrome include internal herniation, colonic volvulus, bowel obstruction, and perforation. , ,