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Chilaiditi Syndrome - A Benign Air Under Diaphragm

A benign "Air Under Diaphragm" a rare condition reported in Emergency Department ,Kuala Lumpur General Hospital Case presented in 4th International Clinical Conference in Emergency Medicine 2015

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Baran Palanimuthu
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357 views1 page

Chilaiditi Syndrome - A Benign Air Under Diaphragm

A benign "Air Under Diaphragm" a rare condition reported in Emergency Department ,Kuala Lumpur General Hospital Case presented in 4th International Clinical Conference in Emergency Medicine 2015

Uploaded by

Baran Palanimuthu
Copyright
© © All Rights Reserved
We take content rights seriously. If you suspect this is your content, claim it here.
Available Formats
Download as PDF, TXT or read online on Scribd
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Chilaiditi Syndrome

A false Air Under Diaphragm imagery


Department of Emergency Medicine and Trauma
Hospital Kuala Lumpur, Kuala Lumpur 50586 MALAYSIA
Baran Palanimuthu, Alzamani Idrose

Introduction
Pneumoperitoneum is a surgical emergency. Nevertheless,
pseudopneumoperitoneum can mimic one leading to unnecessary
imaging, investigation and treatment.

Case Description
69 years old Punjabi lady with underlying disease of carcinoma of
pyriform fossa and larynx , hypertension and gastric ulcer
presented to our emergency department complaining of shortness
of breath for the past 5 days and progressively worsening.
Breathlessness was not related to exertion. She claimed of having
abdominal fullness, no bowel output for 2 days but passing out
flatus. She denied any abdominal pain. Her vital signs were normal.
On examination patient had fullness over right upper quadrant.
Rectal examination showed empty rectum. Chest x-ray erect done
showed elevated right diaphragm with bowel shadow under right
diaphragm. Initial diagnosis was to rule out right diaphragmatic
hernia. Chest x-ray was then reported as bowel seen in between
right hemidiaphragm and liver likely represent Chilaiditi Syndrome.
Patient was treated conservatively with fluid and symptoms
resolved after observation in the ward and discharged with no
more symptoms two days later.

Lessons Learnt & Conclusion


Pseudopneumoperitoneum need to be considered if bowel shadow
is noted under the right diaphragm while examination is not
suggestive of acute abdomen. Nevertheless, causes of acute
abdomen need to be ruled out first. Treatment is conservative for
Chilaiditi syndrome.

Discussion
Chilaiditi Syndrome was first described by Greek radiologist Dr
Demetrius Chilaiditi in 1910 as one of the causes of
pseudopneumoperitoneum and it occurs when bowel gas is
interposed between the liver and the hemidiaphragm resulting in
pain. Gas in this position may be misinterpreted as
true pneumoperitoneum. A variety of gastrointestinal symptoms
including abdominal pain, nausea, vomiting, and small bowel
obstruction may present differing from one to another. The
syndrome can lead to severe complications, such as perforation,
intestinal obstruction or bowel ischemia, hence awareness
regarding this syndrome is essential.
Chilaiditi syndrome are relatively rare as only 8 cases have been
reported in Chinese literature from year 1990 to 2013. There are
various causes resulting in this rare phenomena e.g:
1)Large space between liver and diaphragm may result in colonic
interposition
2)Elongated/hypermobile colon with constipation
3)Abnormal gas distribution secondary to aerophagia
Chiladiti syndrome can be diagnosed based on CXR erect.
A characteristic marker of Chilaiditi is the observation of air below
the diaphragm, with visible haustral folds or valvulae conniventes
between the liver and the diaphragmatic surface.
In addition, the location of the air is not changed by altering the
position of the patient. It is important to differentiate true
pneumoperitoneum from Chilaiditi sign. Pneumoperitoneum
normally shows a crescent-shaped gas shadow under the
diaphragm without haustral folds or valvulae conniventes, and
altering the posture of the patient changes the position of the gas.
Patients with pneumoperitoneum usually exhibit injury to the
hollow viscus and simultaneously shows signs of peritonitis.
However in this case, patient did not posses any signs of
peritonitis. Patient was only complaining of abdominal fullness. On
examination, the abdomen was soft, non-tender, bowel sound
present. Bedside ultrasound showed no free fluid in the intraabdominal cavity
It is necessary for general practitioner and ED doctors to consider
Chiladiti syndrome as one of the differential diagnosis even though
it is considered as a rare syndrome, most probably due to lack of
exposure regarding this condition or not many cases have been
reported by clinicians even though have been encountering in daily
practice
Continuous evidence based learning is crucial for us clinicians to
keep us up to date regarding rare disorders to provide optimal
care and treatment for patient.

References
Bowel gas seen in between liver and right
hemidiaphragm

1.Weng WH, Liu DR,Feng CC, Que RS. Colonic interposition between liver and left
diaphragm-Management of chilaiditi syndrome: A case report and literature review
.Oncology Letters . 2014 7(5): 16571660
2.National organization of rare disorder. Chilaiditi Syndrome Available from:
https://rarediseases.org/rare-diseases/chilaiditis- syndrome : accesed 1st September 2015
3.Radiopedia.org.
Chilaiditi
syndrome
Available
from:
http://radiopaedia.org/articles/chilaiditi-syndrome : accessed on 2nd September 2015

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