Chilaiditi sign
Chilaiditi sign is a radiologic finding in which a segment of large bowel (often the hepatic flexure) is interposed between the liver and the diaphragm. [1, 2] Chilaiditi syndrome refers to the same anatomic interposition when clinical symptoms are present, most commonly gastrointestinal symptoms. [1, 2]
Symptomatic clinical presentation
Symptomatic hepatodiaphragmatic interposition most often presents with gastrointestinal symptoms such as abdominal pain, nausea, vomiting, and constipation. [2] Respiratory distress can occur. [2] Cardiac symptoms that mimic angina-like pain have been reported less commonly. [2]
Diagnostic distinction from emergent causes
Air under the diaphragm on plain radiograph can mimic pneumoperitoneum. [2, 3] Computed tomography is commonly used to differentiate Chilaiditi sign/syndrome from pneumoperitoneum or subphrenic abscess. [1, 2] Plain-film features such as visible colonic haustral markings below the diaphragm support colonic interposition rather than free intraperitoneal air. [2]
Management in symptomatic patients (initial approach)
Symptomatic patients without evidence of peritonitis, ischemia, perforation, or complicated obstruction should receive conservative management. [1, 3] Conservative measures include bowel decompression and supportive care, followed by reassessment and repeat imaging to confirm resolution. [1] Bowel decompression followed by follow-up radiography is described as a typical approach to demonstrate improvement of the interposed bowel air under the diaphragm. [1]
Management in complicated or nonresolving cases
Surgical consultation is recommended when symptoms are attributable to intestinal obstruction with lack of clinical improvement or failure of conservative therapy. [3] Operative management is indicated when obstruction persists, when volvulus or ischemia is present, or when perforation is suspected or confirmed. [1] Surgical options used in reported cases include colonic resection and/or fixation procedures (such as colopexy or related fixation techniques) depending on the underlying mechanism. [1]
Common pitfalls to avoid
Failure to exclude pneumoperitoneum is a major diagnostic pitfall in patients with subdiaphragmatic free-appearing air. [2, 3] Premature operative management can occur when Chilaiditi sign is not distinguished from true pneumoperitoneum; computed tomography is used to clarify this distinction. [2]
Follow-up and monitoring
Clinical reassessment after decompression is required to ensure symptom resolution. [1] Repeat imaging after decompression is described to confirm disappearance or migration of the interposed bowel air under the diaphragm. [1]