A 73-year-old woman with a history of chronic abdominal pain, constipation, and cholecystectomy 20 years ago presented with symptoms of diarrhea without mucous or blood, and constant pain in the right abdomen. She was febrile (37.7°C) and tachycardic (105 bpm), with a distended abdomen, decreased peristalsis, and abdominal pain worst in the right upper quadrant with an associated mass. Laboratory results revealed leukocytosis (11.6 x 103/µL), AST 176 mU/mL, ALT 198 mU/mL, and alkaline phosphatase 147 U/L. Ultrasound of the liver and biliary tract showed hepatomegaly. Chest radiograph (Figure 1) showed the right hemi-diaphragm elevated above the liver, the intestine distended with air representing a pseudo-pneumoperitoneum, and the upper margin of the liver depressed below the level of the left hemi-diaphragm, consistent with Chilaiditi’s sign.1
Figure 1. (A) Anteroposterior and (B) lateral chest radiographs showing air in the right upper quadrant due to hepatodiaphragmatic interposition of the colon, elevation of the right hemidiaphragm, and inferior and medial displacement of the liver.
A laparotomy showed volvulus of the right colon above the liver with signs of peritonitis, severe ischemia, and microperforation of the cecum. A right hemicolectomy was performed with ileostomy and mucous fistula. Pathology showed an ischemic appendix with liquefactive necrosis, acute peritonitis, and borders of viable resection. The outcome was favorable, and a radiograph showed resolution of Chilaiditi’s sign (Figure 2). She was discharged 7 days after surgery and managed with antibiotics.
Figure 2. Chest radiograph 5 days after surgery does not show bowel loops interposed on the hepatic silhouette.
The etiology of Chilaiditi syndrome—the transposition of the colon between the diaphragm and the liver—has been associated with intestinal factors (abnormal fixation of the colon due to a defect/absence of its suspensory ligaments, congenital malrotation of the intestine), liver factors (agenesis of the right lobe of the liver, cirrhosis), diaphragmatic factors (phrenic nerve injury), chronic lung disease, and obesity.1-3 The differential diagnosis includes pneumoperitoneum, diaphragmatic hernia, intestinal pneumatosis, subphrenic abscess, and hydatid cyst.1-3 The characteristics of the clinical presentation and surgical findings of this patient suggest an episode of acute abdomen due to a cecal volvulus.4
Author contributions: JM Ocampo Chaparro and K. García Mazuera aquired the data and drafted the manuscript. JW Reynolds reviewed the literature and edited the manuscript. CA Reyes-Ortiz designed, edited, and critically revised the manuscript for intellectual content, and is the article guarantor.
Financial disclosure: None to report.
Informed consent was obtained for this case report.
Correspondence: Carlos A. Reyes-Ortiz, MD, PhD, University of Texas Medical School at Houston, Department of Internal Medicine, Division of Geriatric and Palliative Medicine, Houston, TX 77030 (firstname.lastname@example.org).
Received: June 16, 2015; Accepted: October 10, 2015
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