|Year : 2012 | Volume
| Issue : 1 | Page : 9-10
Rare association B/W respiratory distress and chilaiditi syndrome
Santosh Kumar, Gajendra V Singh, Rakesh Singh, Devesh P Singh
Department of TB and Chest Diseases, S.N. Medical College, Agra, India
|Date of Web Publication||10-Dec-2012|
Devesh P Singh
Room No. 8, Doctor's Hostel, In front Department of TB and Chest Diseases, S.N. Medical College, Agra - 282 002
Source of Support: None, Conflict of Interest: None
"Hepatodiaphragmatic interposition of small/large intestine" or "Chilaiditi syndrome" is a rare condition in which colon or small intestine is interposed (temporally or permanently) between liver and diaphragm. The syndrome is usually discovered by chance during the study of another event. The condition is often asymptomatic; however abdominal pain, abdominal distension, vomiting, anorexia, and constipation have previously been reported in clinical presentation of this rare syndrome. We report a 60-year-old female who presented in department of TB and Chest Diseases, S.N. Medical college, Agra with complaints of breathlessness, cough, constipation, and recurrent abdominal pain.
Keywords: Abdominal pain, breathlessness, constipation, chilaiditi syndrome, hepatodiaphragmatic Interposition
|How to cite this article:|
Kumar S, Singh GV, Singh R, Singh DP. Rare association B/W respiratory distress and chilaiditi syndrome. Indian J Allergy Asthma Immunol 2012;26:9-10
|How to cite this URL:|
Kumar S, Singh GV, Singh R, Singh DP. Rare association B/W respiratory distress and chilaiditi syndrome. Indian J Allergy Asthma Immunol [serial online] 2012 [cited 2020 Apr 5];26:9-10. Available from: http://www.ijaai.in/text.asp?2012/26/1/9/104438
| Introduction|| |
Demetrius Chilaiditi originally described three cases of hepatodiaphragmatic interposition of the colon and their associated radiographic findings in 1910. The term Chilaiditi's sign is most often used for peculiar radiographic presentation; however if associated with symptoms, the condition is called as Chilaiditi's Syndrome. 
| Case Report|| |
A 60-year-old woman presented with chronic constipation, recurrent abdominal pain, breathlessness on exertion for last 1 year which was non-progressive and dry cough for last 15 days in department of TB and Chest Diseases S.N. Medical college Agra. On detailed history we found that in past 25 years, many a times this patient had been diagnosed as a case of respiratory tract infections for which she was treated with antibiotics. On several occasions, she has been treated for gastric ulcers.
Even on detailed clinical examination, we were unable to elicit any pathological respiratory findings. Her abdomen was mildly distended, but no organomegaly, mass lesion, or ascites were detected on clinical examination.
Laboratory studies including complete blood count, serum bilirubin, SGOT, SGPT, serum creatinine, RBS, blood urea, and urine analyses were within normal ranges. The patient performed well on pulmonary function tests and spirometry results were within normal limits. Her diffusion lung capacity was also found to be normal. Patient's blood pressure, ECG, and echocardiographic findings were within normal limits.
Patient's chest X-ray revealed elevation of right hemidiaphragm, distended and interposed colonic loop under the right hemidiaphragm, and downward displacement of liver [Figure 1]. On abdominal ultrasonographic examination, the presence of Chilaiditi syndrome was confirmed.
|Figure 1: Chest X-ray showing hepatodiaphragmatic interposition of colon|
Click here to view
| Discussion|| |
Chilaiditi's sign is a relatively rare condition and it's incidence in general population ranges from 0.1% to 1%.  Male to female ratio is 4:1.  The condition is more prevalent in elderly people therefore this condition is believed to be acquired rather than congenital. Remarkably, the prevalence of Chilaiditi's sign in liver cirrhosis patients has been reported to be as high as 22% in a study that used chest X rays.  Choussat H and Choussat-Clausse classified the etiologies into intestinal, diaphragmatic, and hepatic factors. The hepatic factors include ptosis of liver, relaxation of suspensory ligaments, liver fixation because of adhesions, and small liver. Patients with liver cirrhosis tend to have an atrophic liver therefore cirrhosis is considered to be an important cause of this condition. An unusual association between renal tubular acidosis and Chilaiditi syndrome has also been reported,  in which renal tubular acidosis induced hypokalemia caused adynamic ileus which in turn resulted in Chilaiditi syndrome.
The syndrome is usually asymptomatic and most often reported as an incidental finding on abdominal or chest radiographs. If symptomatic, the most common presentations are abdominal pain, distension, vomiting, anorexia, constipation,  etc. Respiratory distress and some severe complications such as volvulus of the colon,  acute intestinal obstruction, etc. have also been reported (although less commonly).
In our case, the lady presented with breathlessness, cough, constipation, and recurrent abdominal pain. The differential diagnosis of peculiar radiographic findings includes pneumoperitonium, sub-diaphragmatic abscess, posterior hepatic lesions, retroperitoneal masses, and omental fat. The fixed gas echo under the right hemi diaphragm on ultrasonography and the absence of the leveling of an air fluid level in the left decubitous position may suggest intra-luminal instead of free gas. ,, The presence of haustra in the hepato-diaphragmatic space aids the differentiation between intraluminal and free gas.
Patients with Chilaiditi syndrome often respond well to non-operative managements like nasogastric decompression and laxatives. The treatment is generally conservative. Surgical management may be recommended in patients with suspected volvulus of the colon, stomach, or small bowel. 
Our patient responded well after conservative management. The patient was given a trial of laxatives and most importantly the patient was advised to change her dietary habits to low fat/high fiber diets. The patient showed considerable improvement in follow up.
In conclusion, the authors believe that Chilaiditi syndrome must be kept in mind in differential diagnosis of abdominal complaints with chronic respiratory symptoms with characteristic radiographic picture of this syndrome.
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