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Chilaiditi sign: A rare differential diagnosis of gas under diaphragm
Rajendra Prasad Takhar1, Motilal Bunkar2, Savita Arya3, Sheema Maqsood4
1Assistant Professor, Dept of Respiratory Medicine, Govt Medical College, Kota, Rajasthan.
2Senior Resident, Dept of Respiratory Medicine, Govt Medical College, Kota, Rajasthan.
3PG Resident, Govt Medical College, Kota, Rajasthan.
4PG Resident, Department of Pulmonary Medicine Peoples Medical College, Bhopal, MP.

Article ID: 100006Z09RT2015
doi:10.5348/Z09-2015-6-CL-6

Address correspondence to:
Rajendra Prasad Takhar
Type First Quarter No.4, Medical College Campus
Rangbari Road
Kota (Rajasthan)
India 324010
Phone: +919784006021

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How to cite this article
Takhar RP, Bunkar M, Arya S, Maqsood S. Chilaiditi sign: A rare differential diagnosis of gas under diaphragm. Case Rep Images Med 2015;1:22–24.

Case Report

A 60-year-old male came to geriatric outpatient department with complaints of breathlessness and right side lower chest pain since 15 days. He denied for fever, nausea/vomiting, abdominal pain and loss of appetite, with normal bowel and bladder habits. He had no significant past surgical or medical history. General physical and respiratory system examination was absolutely normal; abdomen was also soft and did not reveal any sign of peritonitis. All routine blood investigations, pulmonary function test, electro cardiogram (ECG), 2D-echocardiography and ultrasonography of the abdomen showed no abnormality except loop of intestine between the diaphragm and the anterior surface of the liver. His chest skiagram revealed a radiolucent shadow under the right diaphragm with some haustral marking suggestive of interposition of colon between the diaphragm and liver (Figure 1). This radiological finding is called Chilaiditi's sign. The patient was managed conservatively with nasogastric decompression, repeated laxatives and enemas.

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Figure 1: Chest skiagram showing radiolucent shadow under the right diaphragm with some haustral marking suggestive of interposition of colon between the diaphragm and liver-Chilaiditi sign.


Discussion

Intestinal interposition is a medical condition where a segment of the bowel is temporarily or permanently interposed between two organs, for example the liver and the diaphragm, the spleen and the diaphragm, the spleen and the left kidney or the stomach and the pancreas. Among these, the hepatodiaphragmatic interposition is termed Chilaiditi sign and the others are termed non-Chilaiditi sign [1].

Chilaiditi sign is a radiological observation or incidental radiographic finding, associated with right side segmental interposition of the colon between the liver and the diaphragm [2]. It is an incidental imaging finding with an incidence of 0.3% on plain radiography and 2.4% on chest/abdomen computed tomography mostly in elderly male patients. Most patients are asymptomatic but when it is associated with clinical symptoms such as shortness of breath, pain in abdomen, nausea and distention, then it is termed Chilaiditi syndrome [3].

Its cause still remains unknown, but it is probably multifactorial. Table 1 illustrates various predisposing factors for the development of Chilaiditi's sign.

Diagnosis is usually made by chest X-ray, however, CECT scan of chest help in confirmation of diagnosis in suspicious cases.

Differential diagnosis of Chilaiditi's sign or gas under the right diaphragm is: pneumoperitoneum, sub-phrenic abscesses, diaphragmatic hernias and retroperitoneal masses, especially in cases of acute abdomen.

Management: Most patients respond to medical management, and surgery is reserved for those who do not respond to the usual conservative line of management.

Keywords: Chest pain, Chilaiditi's sign, Diaphragm, Gas

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Table 1: Predisposing factors for the development of Chilaiditi's sign



Conclusion

This condition is important for chest physicians because few patients with breathlessness may present with this type of X-ray picture and respiratory pathology is not necessarily involved in such cases. All chest physicians should be aware that shortness of breath is not always due to problems in the chest.


Acknowledgements

All the staff members who were involved in the care of the patient.


References
  1. Bredolo F, Esposito A, Casiraghi E, Cornalba G, Biondetti P. Intestinal interposition: the prevalence and clinical relevance of non-hepatodiaphragmatic conditions (non-Chilaiditi forms) documented by CT and review of the literature. Radiol Med 2011 Jun;116(4):607–19.   [CrossRef]   [Pubmed]    Back to citation no. 1
  2. Sanyal K, Sabanathan K. Air below the right diaphragm: Chilaiditi sign. Emerg Med J. 2008 May;25(5):300.   [CrossRef]   [Pubmed]    Back to citation no. 2
  3. Nagem RG, Freitas HL. Chilaiditi's syndrome: a case report. Radiol Bras 2011;44(5):333–35.    Back to citation no. 3
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Author Contributions
Rajendra Prasad Takhar – Substantial contributions to conception and design, Acquisition of data, Analysis and interpretation of data, Drafting the article, Revising it critically for important intellectual content, Final approval of the version to be published
Motilal Bunkar – Substantial contributions to conception and design, Analysis and interpretation of data, Drafting the article, Final approval of the version to be published
Savita Arya – Acquisition of data, Analysis and interpretation of data, Revising it critically for important intellectual content, Final approval of the version to be published
Sheema Maqsood – Conception and design, Analysis and interpretation of data, Revising it critically for important intellectual content, Final approval of the version to be published
Guarantor of submission
The corresponding author is the guarantor of submission.
Source of support
None
Conflict of interest
Authors declare no conflict of interest.
Copyright
© 2015 Rajendra Prasad Takhar et al. This article is distributed under the terms of Creative Commons Attribution License which permits unrestricted use, distribution and reproduction in any medium provided the original author(s) and original publisher are properly credited. Please see the copyright policy on the journal website for more information.



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