Dyspnea and large bowel obstruction: a misleading Chilaiditi syndrome

Chilaiditi Syndrome: A Rare Case of Chest Pain due to Colonic Interposition

We present an unusual case of Chilaiditi syndrome that manifests under the guise of multiple systemic signs and symptoms. An 81-year-old female patient with a history of coronary artery disease and hypothyroidism presented to emergency department (ED) with chest heaviness associated with nausea, shortness of breath, diffuse abdominal pain and constipation. Her symptoms were similar to the previous episode of ST-segment elevation myocardial infarction. The clinical team ruled out acute coronary syndrome based on electrocardiogram (EKG) and troponin levels. On further testing, CT of the abdomen revealed the interposition of colon on the dome of diaphragm consistent with Chilaiditi sign. The patient was diagnosed with Chilaiditi syndrome based on the characteristic radiological finding and the symptomatic presentation. Conservative management with bowel rest and laxative bowel regimen resolved her symptoms without further complications. A high index of suspicion is required for the early diagnosis and can prevent further complications and mitigate the need for laparoscopic intervention.

A rare cause of sudden chest pain and dyspnea: A CARE-compliant case report of Chilaiditi syndrome

RATIONALE

Chilaiditi syndrome is a rare disorder characterized by a broad spectrum of (gastro-intestinal) symptoms caused by interposition of a segment of bowel between the liver and the diaphragm. Most cases present with abdominal symptoms and the morbidity tend to increase with age.

PATIENT CONCERNS

Here we present a rare case of Chilaiditi syndrome. An elderly postmenopausal woman developed unresolved postoperative respiratory symptoms and chest pain. Chest auscultation revealed considerable attenuation of respiratory sounds. She showed postoperative increase in D-dimer level and sudden onset of dyspnea.

DIAGNOSES

Considering the presence of atelectasis in the middle and lower lobes of the right lung, bedside fiberoptic bronchoscopy was performed immediately to rule out bronchial phlegm embolism. However, no phlegm embolism was found in the left lung, and a small amount of yellow-white mucus was seen in the upper lobe of the right lung. Due to external pressure, the lumen of the middle and lower lobes of the right lung was obviously narrowed.

INTERVENTIONS

The patient was placed in a semi-sitting position and a tube was passed through the anus to decompress the intestinal cavity; in addition, she received potassium supplementation.

OUTCOMES

The patient's symptoms improved markedly. Chest and semi-supine abdominal plain radiographs showed enhanced lung markings, shadows in the left lower lung lobes, elevation of the right diaphragm, and small amount of pneumoperitoneum. The patient recovered after 5 days of continuous treatment and was discharged.

LESSONS

Emergency computed tomographic pulmonary angiography may facilitate the diagnosis of Chilaiditi syndrome, especially in the postoperative setting. Occurrence of Chilaiditi syndrome in this patient was likely associated with surgical factors. Appropriate investigations and clear identification of etiology are essential for successful treatment.

Death Caused by Hepatodiaphragmatic Interposition of the Colon

Hepatodiaphragmatic interposition of the colon is a rare, usually asymptomatic, anomaly and is typically an incidental radiologic finding. There are few cases in the literature describing the symptomatic form of the condition, known as Chilaiditi syndrome. In some cases, it may be accompanied by various severe complications. If symptoms are present, usually conservative treatment is given. However, conservative treatment only addresses the symptoms but does not prevent their recurrence and possible complications. Our present report shows that this anomaly may not only cause symptoms, but may also progress and cause severe complications, in our case-megacolon leading to right heart failure and, ultimately, death. To date, however, there have been no literature reports of death caused by colonic interposition. Therefore, it is important to draw attention to the importance of this anomaly and its appropriate diagnosis and treatment to ensure the most favorable patient outcomes.

Ogilvie Syndrome and Chilaiditi Syndrome: a Strange Association

Chilaiditi syndrome is a strange disease which includes the existence of Chilaiditi sign and other abdominal symptoms. Chilaiditi sign refers the interposition of the colon between the liver and diaphragm that could be misinterpreted to be a pneumoperitoneum. We present a 46-year-old male patient who was admitted in the hospital with constipation and abdominal oppressive pain located in the epigastric area. He showed signs of peritoneal irritation, no bowel sounds, hernias, or organ enlargements. Laboratory analysis only revealed CPK elevation (462 U/L). Abdominal and chest radiographs showed an image which suggested a pneumoperitoneum. The patient underwent emergency surgical treatment, under diagnosis of viscera perforation. At laparotomy, an interposition of the transverse colon between the liver and diaphragm were visualized, although no perforations were present. Psychiatric treatment was held until this moment due to the high risk of schizophrenia outbreak. During the next 48 h, intestinal transit was restored and he was discharged on postoperative day 40, diagnosed with Ogilvie syndrome secondary to psychotropics. The relationship between Ogilvie syndrome and psychiatric treatments is known, but the association between Ogilvie and Chilaiditi syndrome is very strange. Nevertheless, it could be misinterpreted like a pneumoperitoneum and led to the performance of emergency surgery.