Chilaiditi sign

Chilaiditi sign is the radiological appearance (often seen on chest X-ray) of a transposition of loop of colon in between diaphragm and liver (the appearance of air under dome of right diaphragm)

• was first described by a Greek radiologist Demetrius Chilaiditi in 1910
• a rare radiologic finding where colonic interposition occurs between the diaphragm and the liver: hepatodiaphragmatic interposition
• diagnosis is usually found incidentally on images obtained for other diagnostic reasons
  
  
• incidence is around 0.1-1% - most patients are asymptomatic (1)
  
  
• may be seen in liver cirrhosis and COPD
  
  
• a contributory cause of chilaiditi sign may be redundant mobile colon due to laxity of suspensory ligament of large intestine or liver; or elevation of the right diaphragmatic copula due to phrenic nerve paralysis
  
  
• other possible associated conditions include:
  • colonic volvulus (2,3) and
  • few colonic malignancies (4)
    
    
• diagnosis is generally made by X-ray; CT scan will help in confirmation of diagnosis in case of suspicion
  • chest and abdominal plain X-rays are not as sensitive for the diagnosis as CT scans (5)
    
    
• symptomatic presentation with chilaiditi sign is termed as chilaiditi syndrome
  • shortness of breath may occur (1)
  • sometimes, other symptoms like pain in abdomen, nausea and distention can be the presenting symptoms
    
    
  • conservative management is the only required treatment in most cases with bed rest, intravenously administered fluid support, and bowel decompression playing a significant role in alleviating the symptoms
    • if the cause of the presentation is with complicated abdominal pathologies, including obstruction, volvulus, or perforation, conservative management cannot correct the underlying pathology and surgical intervention is warranted (6,7)
    • surgical options for complicated Chilaiditi syndrome range from:
      • resection of the involved part of the colon (that is, right hemicolectomy) or
      • fixation of the liver (that is, hepatopexy) to the abdominal wall to obliterate the potential space and prevent colonic displacement

Reference:

• Sanyal K, Sabanathan K. Air below the right diaphragm: Chilaiditi sign. Emerg Med J. 2008;25:300.
• Loke KL, Chan CS. Case report: Transverse colon volvulus: Unusual appearance on barium enema and review of the literature. Clin Radiol. 1995;50:342-4.
• Eisenstat TE, Raneri AJ, Mason GR. Volvulus of the transverse colon. Am J Surg. 1977;134:396-9.
• Yagnik VD. Chilaiditi sign. Lung India. 2010 Jul-Sep; 27(3): 190.
• Saber AA, Boros MJ. Chilaiditi's syndrome: what should every surgeon know? Am Surg. 2005;71:261-3.
• Blevins WA, Cafasso DE, Fernandez M, Edwards MJ. Minimally invasive colopexy for pediatric Chilaiditi syndrome. J Pediatr Surg. 2011;46(3):e33-5.
• Takahashi K, Ito H, Katsube T, Tsuboi A, Hashimoto M, Ota E, et al. Treatment of Chilaiditi syndrome using laparoscopic surgery. Asian J Endosc Surg. 2017;10(1):63-5.