4 Conclusionįree air under the diaphragm is a concerning finding.
Chilaiditi’s sign has been associated with subphrenic abscess, intestinal obstruction of the large or small bowel, Ogilvie syndrome, volvulus of the transverse colon or splenic flexure, cecal perforation, subdiaphragmatic appendicitis, and the anatomic variants listed previously have been reported in the literature. In both patients, the CT scan was diagnostic and should be the imaging study of choice as it is quick and readily available. Factors contributing to the occurrence of Chilaiditi’s sign include the absence of normal suspensory ligaments of the transverse colon abnormality or absence of the falciform ligament redundant colon that may be seen with chronic constipation or in bedridden individuals aerophagia, paralysis, or eventration of the right hemidiaphragm chronic lung disease, cirrhosis, or ascites. Left lateral decubitus plain films can help in this distinction. 3Ī feature on a plain radiograph that suggests Chilaiditi’s sign instead of pneumoperitoneum is the presence of haustral folds or plicae circulares within the gas that suggest the gas is within the bowel and not free. 2 The term Chilaiditi’s syndrome has been used when this sign is associated with symptoms like nausea, vomiting, anorexia, abdominal pain, and respiratory distress. 1 Rare case reports have also reported so-called left-sided Chilaiditi’s sign with the splenic flexure interposed between the diaphragm and spleen.
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Pathology confirmed the findings of a grossly dilated cecum and acute appendicitis (Figure 1d).Ĭhilaiditi’s sign is a rare radiological sign that is described as the anterior interposition of the colon or the small intestine between the liver and the undersurface of the right diaphragm that may be mistaken as free intra-abdominal air. The patient’s postoperative course was uneventful, and he was discharged home on postoperative day six. A decision was made to convert to a laparotomy, and we performed a right hemicolectomy with a stapled ileocolic anastomosis. The inflamed appendix was found to be retrocecal in position. He underwent diagnostic laparoscopy, where a dusky and grossly dilated cecum was found to be wedged between the diaphragm and the right lobe of the liver. The patient had cecal pneumatosis and an acutely inflamed appendix with a maximum diameter of 16 mm (Figure 1c). It appeared that the cecum had folded superiorly and anteriorly, becoming entrapped between the liver and the diaphragm (Figure 1b). A CT of the abdomen did not reveal any traumatic injury but did demonstrate a grossly dilated cecum up to 18 cm. Chest plain film showed what appeared to be air under the right hemidiaphragm (Figure 1a). The patient was hemodynamically stable with abdominal tenderness in the right upper quadrant with focal guarding. He noted some diarrhea but had had no flatus since the night before. The day before he presented, he had fallen onto his right side while standing later that same evening, he began experiencing right upper quadrant and lower thoracic pain. Key WordsĬhilaiditi’s sign acute abdomen pneumoperitoneum: cecal bascule Morgagni’s hernia Case Description Case OneĪ 67-year-old male with a history of stroke and partial left hemiparesis presented to our facility with right upper quadrant pain. A thorough surgical exam and additional imaging will help delineate the true etiology of abdominal pain and triage patients appropriately. ConclusionĬhilaiditi’s sign can be associated with an acute abdomen. She underwent an elective laparoscopic hernia repair, which confirmed the presence of an anteromedial diaphragmatic hernia containing small bowel, colon, and omentum. An upright chest X ray revealed air under the right hemidiaphragm, and the CT scan demonstrated a large, right-sided Morgagni-type diaphragmatic hernia. The second patient was a 59-year-old female who presented with acute onset of right-sided abdominal pain. Diagnostic laparoscopy confirmed imaging findings, and he underwent an open right hemicolectomy. A CT scan revealed a cecal bascule interposed between the liver and diaphragm with concomitant acute appendicitis. He was found to have Chilaiditi’s sign on the upright chest X ray.
The first patient was a 67-year-old male who presented with right upper quadrant pain.
We present two cases of Chilaiditi’s sign resulting from vastly different pathologies. Chilaiditi’s sign can be mistaken for pneumoperitoneum and can be alarming in the setting of an acute abdomen. Chilaiditi’s sign is a rare radiologic sign where the colon or small intestine is interposed between the liver and the diaphragm.
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