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

Unveiling the Chilaiditi Syndrome: A Case Report and Management Implications

The Chilaiditi syndrome is when the radiologic Chilaiditi sign, defined by the interpositioning of the colon between the liver and diaphragm, becomes complicated by clinical symptoms such as respiratory insufficiency or bowel obstruction. We present the case of a 70-year-old male with a history of depression, anxiety, gastroesophageal reflux disease (GERD), and post-polio syndrome, who presented with left shoulder pain, chronic weakness, and dizziness. Initial evaluation revealed hypotension and elevated lactic acid, attributed to dehydration. Further imaging identified a Chilaiditi sign, thus raising suspicion of small bowel obstruction and the Chilaiditi syndrome. Despite conservative management, the patient continued to experience elevated lactic acid levels, prompting a computed tomography (CT) angiogram to rule out bowel ischemia. No acute intra-abdominal pathology was identified, and the patient improved with hydration and bowel rest. This case highlights the challenges in diagnosing and managing the Chilaiditi syndrome in the setting of chronic comorbidities.

Chilaiditi Syndrome: A Case Report, Literature Review, and Proposition of a Novel Management Staging System

Chilaiditi's sign refers to colonic interposition between the liver and the diaphragm in the right subphrenic space secondary to the relaxation of the suspensory ligaments of the right colic flexure. The diagnosis of Chilaiditi's sign is based on radiological findings with the following three criteria: 1) The right hemidiaphragm must be adequately elevated above the liver by the intestine, 2) the bowel must be distended by air to illustrate pseudo-pneumoperitoneum, and 3) the superior margin of the liver must be depressed below the level of the left hemidiaphragm. In this report, we present the case of a 49-year-old female presenting with signs and symptoms suggestive of Chilaiditi syndrome managed with laparoscopic surgery. We also present a literature review with a summary of previous studies and propose a novel management staging system for this syndrome.

Chilaiditi syndrome: A structural displacement in a heart failure patient

Background

Chilaiditi's sign is often found incidentally on chest or abdominal radiograph and can be accompanied by clinical symptoms such as abdominal pain, gastrointestinal complications, and less commonly associated with dyspnea.

Case presentation

In this interesting case, we discover lingering dyspnea in our 79 year old male with a past medical history of asthma and heart failure with preserved ejection fraction admitted for acute heart failure exacerbation with reduced ejection fraction along with a new incidental finding of Chilaiditi's sign on chest radiograph. Patient received optimal diuretics and guideline-directed medical treatment for heart failure exacerbation, but mild dyspnea with pleuritic chest pain persisted. Dyspnea with pleurisy was likely attributed to a structural anatomical defect (Chilaiditi's sign) that can be picked up on imaging.

Conclusion

Chilaiditi syndrome can be an incidental cause of ongoing persistent dyspnea, and if symptoms are severe, intervention can be warranted for symptomatic resolution.

Learning objective

Chilaiditi syndrome should be considered as a possible diagnosis among patients with a history of heart failure and incidental Chilaiditi's sign on chest radiographic imaging who suffer from persistent dyspnea and pleurisy despite optimal diuretics and guideline-directed medical treatment.

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Chilaiditi's sign in an incidental finding on chest or abdominal radiograph associated with gastrointestinal symptoms and less commonly associated with dyspnea.

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Chilaiditi's sign with underlying heart failure is not well understood.

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Chilaiditi syndrome should be considered as a possible diagnosis among patients with a history of heart failure and incidental Chilaiditi's sign on chest radiographic imaging who suffer from persistent dyspnea and pleurisy despite optimal diuretics and guideline-directed medical treatment.

An Atypical Case of Chilaiditi Syndrome

Chilaiditi's sign is a rare radiological finding in which a portion of the colon or small intestine is interposed between the liver and right hemidiaphragm. We present a 28-year-old male who came to the emergency room with nausea and vomiting. A computed tomography scan without contrast of the abdomen and pelvis showed a new focus of air in the perihepatic region, suggesting a pneumoperitoneum or a loop of bowel. Exploratory laparotomy was pursued but deferred after a multi-disciplinary review of the imaging. A decision was made to pursue conservative management with a diagnosis of Chilaiditi syndrome. This case illustrates the importance of maintaining a broad differential when approaching a patient with abdominal distress and possible pneumoperitoneum, especially when the clinical picture does not align with radiological findings. Early consideration of Chilaiditi syndrome is important to minimize unnecessary surgical intervention such as laparotomy or further endoscopic intervention, which may lead to potential complications such as perforation, bowel wall ischemia, or respiratory failure.