|Year : 2014 | Volume
| Issue : 3 | Page : 200-202
Chilaiditi's syndrome masquerading as chest pain
Arjun Goel, Neeraj K Dewanda
Department of General Surgery, Government Medical College and Associated Group of Hospitals, Kota, Rajasthan, India
|Date of Web Publication||19-Sep-2014|
Room No. 1, PG Hostel 2, MBS Hospital, Nayapura, Kota - 324 001, Rajasthan
Source of Support: None, Conflict of Interest: None
Chilaiditi syndrome is a condition in which the colon or rarely the small bowel is interposed temporarily or permanently between the liver and the diaphragm. Usually it is an asymptomatic and incidental radiographic finding, but may present with a variety of symptoms. We report a case of Chilaiditi syndrome with small bowel interposition who presented with chest pain, initially suspected to be myocardial infarction. Further Investigations revealed normal cardiac functions and gas under the right hemidiaphragm suggestive of pneumoperitoneum. After careful inspection of radiograph it was found to be gas filled small bowel between liver and diaphragm, which was later confirmed by ultrasound examination. The patient was successfully managed conservatively.
Keywords: Chest pain, Chilaiditi′s syndrome, small bowel
|How to cite this article:|
Goel A, Dewanda NK. Chilaiditi's syndrome masquerading as chest pain. J Sci Soc 2014;41:200-2
| Introduction|| |
Hepatodiaphragmatic interposition of small or large bowel, known as Chilaiditi's syndrome, was first identified by Chilaiditi in 1910.  The interposed bowel loops are generally the hepatic flexure of colon and much less frequently small bowel.  Patients with this anomaly may be asymptomatic. However, they may manifest with abdominal pain, anorexia, vomiting, and constipation that may require surgical intervention.  To the best of our knowledge, only three cases of Chilaiditi's syndrome with chest pain have been reported so far. ,, The case of Chilaiditi's syndrome reported here is peculiar with regard to its symptoms, that is angina like chest pain and the interposition of small bowel in the hepatodiaphragmatic space, both of which are rare presentations. The patient was correctly diagnosed with basic investigations and managed conservatively.
| Case report|| |
The case we present here is about a 72-year-old man who presented with the complaints of chest pain associated with nausea and constipation. On examination, he was hemodynamically stable with normal cardiovascular examination. Bilateral chest was clear on auscultation. His abdomen was distended and nontender, nonrigid, and guarding was absent. Bowel sounds were normal. Rectal examination revealed hard stools in the rectum. His blood investigations were within the normal limits. Considering his age, initially myocardial infarction was suspected as the cause of his chest pain. Electrocardiogram and cardiac enzymes were done and found to be within the normal limits. Chest radiograph showed gas under right hemidiaphragm raising the suspicion of perforated bowel. Due to the discrepancy between clinical findings of the abdomen, which were not suggestive of perforation peritonitis and radiological findings, a closer inspection of the X-ray was done. It showed markings of valvulae connivantes suggestive of small bowel loop interposition between the liver and right hemidiaphragm [Figure 1], which was later confirmed by ultrasound examination.
|Figure 1: Chest radiograph showing radiolucent shadow under right hemidiaphragm suggestive of gas (white solid arrow) with marking suggestive of valvulae conniventes (white arrow head)|
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The patient was managed conservatively by bed rest, antacids, laxatives, and rectal enemas. The patient gradually improved with relief of chest pain, abdominal distension, constipation, and other symptoms. Repeat radiographs showed disappearance of the Chilaiditi's sign. The patient was discharged on the 5 th day and is asymptomatic on follow-up.
| Discussion|| |
Chilaiditi's syndrome is a rare condition and is reported to have incidence ranging between 0.025% and 0.28% in the general population  with Male: Female ratio of 4:1.  Factors contributing to its occurrence are thought to include absence of normal suspensory ligaments of the transverse colon, abnormality or absence of falciform ligament, redundant colon, paralysis or eventration of the right hemidiaphragm, chronic constipation, shrunken liver, cirrhosis, ascites, phrenic nerve injury, aerophagia, chronic lung disease, obesity, and multiple pregnancies. It has also been associated with a variety of pulmonary or gastrointestinal malignancies, involving the colon, rectum or stomach.  The condition can be confused with pneumoperitoneum and subphrenic abscess radiologically. The presence of haustrations or valvulae connivantes and fixation of position of radiolucency when the position of the patient is changed point towards Chilaiditi's sign. 
The small bowel loop interposition is rare occurring in 3-5% of Chilaiditi's signs and patients are more often symptomatic when the small bowel is interposed.  In patients with Chilaiditi's syndrome, the most common symptoms are gastrointestinal (e.g., abdominal pain, nausea, vomiting, and constipation) followed by respiratory distress and less frequently angina like chest pain. 
Complications of Chilaiditi's syndrome may include a volvulus of the caecum, splenic flexure or transverse colon, cecal perforation, and rarely perforated subdiaphragmatic appendicitis. If a radiograph or ultrasound cannot clearly determine whether the subdiaphragmatic air is free or intraluminal, a computed tomography scan is recommended to establish an accurate diagnosis, assuming the patient is clinically stable. 
Initial management of Chilaiditi's syndrome should include bed rest, nasogastric decompression, intravenous fluid therapy, bowel decompression, enemas and laxatives. Follow-up radiograph can confirm both the diagnosis of the condition and success of the therapy. If the patient does not respond to initial conservative management then surgical intervention is indicated.  Many of the cases reported so far have been surgically explored. ,,,
| Conclusion|| |
Chilaiditi's syndrome is a rare condition caused by the interposition of the colon or less frequently the small bowel into the hepatodiaphragmatic space. It may rarely present with chest pain causing a diagnostic dilemma for the physician. When confronted with radiographs showing gas under the right hemidiaphragm without signs suggestive of perforation, we should keep this syndrome as differential diagnosis. When there is a discrepancy between the clinical features and X-ray findings, greater reliance should be placed on the clinical findings, keeping in mind the age old time honored adage "treat the patient and not the investigations."
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