Chilaiditi's syndrome: what should every surgeon know?

Chilaiditi's sign mimicking a traumatic diaphragmatic hernia

A 75-year-old man had bruising develop after a traffic accident. A chest roentgenogram revealed elevation of the right hemidiaphragm. A subsequent computed tomographic scan showed interposition of the colon between the liver and diaphragm in front of the liver. Initially, we suspected a traumatic diaphragmatic hernia. Urgent exploratory video-assisted thoracoscopic surgery showed no injury of the right diaphragm. With the benefit of hindsight, there was no rupture of the diaphragm on the image. Hepato-diaphragmatic interposition of the colon is a very rare anomaly. This case was "Chilaiditi's sign" mimicking a traumatic diaphragmatic hernia.

Radiographic look-alikes: distinguishing between pneumoperitoneum and pseudopneumoperitoneum

BACKGROUND

Air under the diaphragm seen on plain radiograph usually signifies a perforated viscus. This represents a surgical emergency and an immediate consult with the surgeon. However, not all air under the diaphragm seen on plain radiograph represents a surgical emergency.

OBJECTIVES

This article will present two cases with air under the diaphragm, but with different diagnoses and management. The first case is an example of pneumoperitoneum from a perforated viscus. The second case is an example of pseudopneumoperitoneum from Chilaiditi syndrome, which will be discussed.

CASE REPORTS

The first case is a 45-year-old woman who presented with bloating, nausea, and vomiting after being diagnosed with diverticulitis 4 days before evaluation. The patient was noted to be febrile and tachycardic. A chest radiograph was obtained, which showed air under the diaphragm. A surgeon was consulted who performed a laparotomy on the patient. Patient was diagnosed with a perforated viscus from a sigmoid diverticulitis. The second case is a 68-year-old woman who presented with right-sided abdominal pain, cough, nausea, and vomiting. A chest radiograph showed possible free air under the diaphragm. A computed tomography scan of the abdomen showed Chilaiditi syndrome, large bowel transposed between the liver and the diaphragm, but no free air. The patient was treated symptomatically and discharged home.

CONCLUSION

It is important for physicians to be able to distinguish pneumoperitoneum and pseudopneumoperitoneum to allow proper diagnosis and treatment.

Delayed diagnosis of infarcted small bowel due to right-sided Bochdalek hernia

We report a case of an adult patient with small bowel infarction, secondary to a strangulated Bochdalek hernia.

[Chilaïditi's syndrome responsible for an occlusion with necrosis of the small intestine after a caesarean section: first case report]

Chilaïditi's syndrome is the association of a radiological and clinical semiology of the interposition of large colon or small intestine between the lower side of diaphragm and liver. We report the case of a 32-year-old woman, primigravida, who undergone a caesarean section at 39 weeks of amenorrhoea, for a clinical picture of persistent abdominal pain and a beginning hepatic cytolysis. The patient presented one day after the ceasarean section an occlusive syndrome of the small intestine. The etiology of the occlusion of the small intestine in post-partum was a Chilaïditi's syndrome with inter hepatodiaphragmatic incarceration of the small intestine discovered at the computed tomography. An exploratory laparotomy confirmed and permitted to treat Chilaïditi's syndrome complicated by an occlusion.