Chilaiditi syndrome in a Nepalese girl - A potential mislead!

Intensive Care Management of an Adult Patient With Rare Chilaiditi Syndrome Presenting as Abdominal Breathing: A Case Report

Chilaiditi syndrome (CS) is an uncommon case of the asymptomatic radiographic finding of an intestinal loop between the liver and the diaphragm. The most crucial phases in the diagnosis process are a thorough physical examination and precise imaging, particularly in challenging disorders such as CS. The presence of free air under the right hemidiaphragm in this syndrome, the diagnosis of which is based on radiographic imaging, might direct the start of treatment without the need for surgical intervention. An 86-year-old man, with asthma and chronic obstructive pulmonary disease (COPD) was checked out in our hospital's emergency department (ED) after experiencing nausea and vomiting. Having abdominal breathing while the patient was in an internal medicine department owing to a urinary tract infection (UTI) and acute kidney injury (AKI), he was moved to the intensive care unit (ICU). The patient was treated with respiratory physiotherapy, inhaler bronchodilator treatment, antibiotic therapy, enema, and laxatives. Medical imaging is the primary diagnostic tool for CS, guided by the symptoms. In patients like this elderly patient who was taken to ICU from internal medicine due to acute respiratory failure and abdominal breathing, when free air is detected in the subdiaphragmatic region, control should be provided with computed tomography (CT), and non-invasive mechanical ventilation should be applied.

A Rare Presentation of Pseudo-Pneumoperitoneum Secondary to Chilaiditi Sign and Chilaiditi Syndrome in Two Pre-adolescent Females: A Case Series

Chilaiditi sign is defined as the interposition of the colon or small intestine between the liver and the right diaphragm in the absence of symptoms. Chilaiditi syndrome refers to the condition where the Chilaiditi sign is associated with symptoms including abdominal pain. In this series, we present the cases of two pre-pubescent patients with these rare conditions.  A 10-year-old female with a history of autism, IgA deficiency, and constipation presented for gastrointestinal studies due to weight loss and constipation. An abdominal X-ray revealed bowel gas under the right hemidiaphragm and colonic interposition between the diaphragm and the liver, raising concerns for the Chilaiditi sign. She underwent a bowel cleanout, with studies revealing colonic dysmotility and compartmentalization of the sigmoid colon and rectum with the absence of coloanal reflex. A nine-year-old female with a history of constipation, developmental delay, and hypotonia presented with abdominal pain, vomiting, constipation, and decreased appetite. She also manifested tachypnea, abdominal distension, and abdominal tenderness, with an abdominal X-ray revealing a dilated colon interposed between the liver and diaphragm, confirming Chilaiditi syndrome. Prior gastrointestinal studies showed dilated and redundant sigmoid colon and dyssynergia. The treatment entailed rectal irrigations and catheter decompression, which led to the improvement of symptoms. Conservative treatment is the treatment of choice for patients with Chilaiditi sign or Chilaiditi syndrome. It is important to distinguish Chilaiditi syndrome, a common cause of pseudo-pneumoperitoneum, from true pneumoperitoneum, as this diagnosis warrants immediate surgical intervention. Surgical treatment is indicated when there are signs of bowel obstruction or ischemia and for cases with recurrent Chilaiditi syndrome. Raising awareness about this condition is important to reduce the incidence of misdiagnosed surgical emergencies and resulting exploratory surgeries, as well as to avoid high-risk colonoscopies. Chilaiditi sign and Chilaiditi syndrome are relatively uncommon entities, and their prevalence is very rare in the pediatric population. Hence, we believe this case series will contribute to providing clinical awareness of these major complications and avoiding invasive interventions due to the inaccurate diagnosis of these conditions as pneumoperitoneum.

A rare case of asthmatic patient with left Chilaiditi's syndrome

The following case report aims to highlight the rarity of the case in question, in which there is left Chilaiditi syndrome in a patient with bronchial asthma. The patient is a 79-year-old woman who arrived in January 2023 at my facility for episodes of recurrent dyspnea, chest heaviness, wheezing, eructation, dysphagia, epigastric abdominal pain associated with frequent episodes of bronchitis. He performed simple spirometry which showed mixed mild-moderate ventilatory deficit with reduction of small airway volumes, reduced peak expiratory flow and negative broncho reversibility tests for asthma. At 3 months, the patient returned to my attention with a chest radiograph showing marked elevation of the left hemidiaphragm with deviation of the cardiac shadow to the right. He repeated the spirometry which resulted in a clear improvement compared to the previous control with an important variation of the peak respiratory flow during ICS/LABA, the objective finding previously found disappeared, this indicating the presence of an underlying bronchial asthma. The radiological picture was identified by me as Left Chilaiditi Syndrome, as the patient had gastrointestinal symptoms which accompanied the procession of respiratory symptoms. The diagnostic suspicion must be early in these pathologies and the proton pump inhibitors and new generation alginates with the presence of hyaluronic acid and melatonin must also be included in the treatment of the symptoms, which have an important action on gastroesophageal reflux disease (GERD) secondary to this herniation of the viscera into the thoracic cavity. The rarity is represented by the left localization of the diaphragmatic pathology.