This case report describes a rare case of Chilaiditi Syndrome with sigmoid volvulus that required surgical intervention. Chilaiditi Syndrome is a condition where the colon is interposed between the liver and diaphragm. The patient presented with abdominal pain and vomiting and was found to have a dilated gas-filled hepatic flexure between the liver and diaphragm, indicating Chilaiditi Syndrome. Further imaging revealed a sigmoid volvulus complicating the Chilaiditi Syndrome. The patient underwent exploratory laparotomy where the sigmoid volvulus was resected and anastomosis performed. Though rare, Chilaiditi Syndrome can cause serious complications like volvulus and requires differentiation from other abdominal

1. How to site this article: Sandip Kumar Pradhan, Mamata Singh, Asit Behera, Rosalin Routray. Chilaiditi syndrome – A case report.
MedPulse – International Medical Journal July 2015; 2(7): 406-408. http://www.medpulse.in (accessed 24 July 2015).
Case Report
Chilaiditi syndrome – A case report
Sandip Kumar Pradhan1
, Mamata Singh2
, Asit Behera3*
, Rosalin Routray4
1
Consultant Surgeon,
2
Consultant Radiologist,
3
Consultant Internal Medicine,
4
Research Associate, Ashwini Hospital, Cuttack, CDA, Odisha,
INDIA.
Email: drasitmd@gmail.com
Abstract Chilaiditi Syndrome is a rare condition which presents as hepatodiagphargmatic or hemidiagpharmatic interposition of
colon, causing symptoms. The hallmark of the treatment is conservative management with rare surgical indication. We
report a rare case of Chilaiditi Syndrome with volvulus of sigmoid colon which required surgical intervention.
Keywords: chilaiditi syndrome, sigmoid volvulus.
*
Address for Correspondence:
Dr. Asit Behera, Consultant Internal Medicine, Ashwini Hospital, Cuttack, CDA, Odisha, INDIA.
Email: drasitmd@gmail.com
Received Date: 09/07/2015 Revised Date: 16/07/2015 Accepted Date: 19/07/2015
INTRODUCTION
Chilaiditi sign is defined as the interposition of bowels
between the liver and right diaphragm. Chilaiditi sign is
also referred to as hemidiaphragmatic interposition of the
colon. This sign was first described in the medical
literature in 1910 by the Greek radiologist Demetrius
Chilaiditi. Chilaiditi sign has a reported incidence of
0.025% to 0.28% in general population1
and typically
involves the hepatic flexure or transverse colon
sometimes the sigmoid colon. A radiologic finding of
hemidiaphragmatic interposition of the colon is referred
to as Chilaiditi sign, while a symptomatic case is known
as Chilaiditi Syndrome2
. Abdominal pain, constipation,
vomiting, respiratory distress, anorexia, Volvulus and
obstruction are possible presentations of Chilaiditi
syndrome.
CASE REPORT
A 28 year male presented in the ER with the complain of
acute abdominal pain since morning, pain was more
localized on the right side of the abdomen, sharp in nature
without any radiation, not relieved with food. He vomited
8-10 times since morning, mostly watery with bilious.
There was no relief of pain after vomiting. Obstipation
for 2 days. Past history of similar episode 4 months back
treated conservatively. Patient a known case of deaf and
dumb. O/E Pulse-120/m, BP 130/88mmHg, Temp-N,
Spo2=99%, HGT=118mg%. dehydration ++. No pedal
edema, no jaundice. Chest: B/L vesicular BS, no added
sound.CVS: S1 S2 normal with sinus tachycardia, no
murmur. Abdomen: Soft, distension more on the right
side, tenderness generalised, Liver and spleen not
palpable, no ascites, Bowel sound present. No guarding
and rigidity. Liver dullness obliterated. External genitilia
–Normal, Hernial orifices –Normal. P/R examination:
Normal anal canal and rectum. No bleeding, no fecal
impaction. Plain X-ray of the abdomen done in the ER
showed a large gas filled bowel loop in the right
hypochondrium obscuring the hepatic shadow. No other
gas filled bowel seen. (Figure 1)
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DOI: 21 July 2015

2. MedPulse – International Medical Journal, ISSN: 2348-2516, EISSN: 2348-1897, Volume 2, Issue 7, July 2015 pp 406-408
Copyright © 2015, Statperson Publications, MedPulse – International Medical Journal, ISSN: 2348-2516, EISSN: 2348-1897, Volume 2, Issue 7 July 2015
Figure 1: Abdominal radiography shows a large bowel gas between diagphargm and liver pushing it towards left
Patient was admitted with a provisional diagnosis of volvulus?? Investigations: Hb-16.1gm%, TLC -19,900/cmm, P-
94%, RBS=158gm%, Sr.Crt=1.2mg/dl, urea-24 mg/dl, Sr Amylase=28 U/L, Lipase=19 U/L. USG: Minimal Peritoneal
Collection, Interposition of dilated gas filled hepatic flexure In between liver and diaphragm. (Chilaiditi Syndrome)
(Figure 2)
Figure 2 Figure 3 Figure 4
The CT abdomen with contrast was reported as: Volvulus
involving sigmoid and descending colon with
interposition of obstructed descending colon between
liver and diaphragm.(Figure 3, Figure 4) (F/S/O
complicated Chilaiditi Syndrome). Patient was initially
managed conservatively with nasogastric aspiration,
intravenous fluid, antibiotics, analgesic, Proton pump
inhibitors, and enema with good result. Later after the CT
findings patient was taken up for Exploratory
Laparotomy. Findings: Large sigmoid volvulus with
bands of adhesion in the sigmoid mesentry. The sigmoid
loop was insinuated between the liver and the right
hemidiaphragm. Multiple adhesion of the loop with the
caecum and terminal ileum. There was interloop adhesion
of the mid ileum.(Figure 5, Figure 6) Procedure done:
Resection of the sigmoid volvulus (Figure 7) and
anastomosis of the descending colon with the rectum and
adhesinolysis.
Figure 5 Figure 6 Figure 7

3. Sandip Kumar Pradhan, Mamata Singh, Asit Behera, Rosalin Routray
MedPulse – International Medical Journal, ISSN: 2348-2516, EISSN: 2348-1897, Volume 2, Issue 7, July 2015 Page 408
DISCUSSION
There are many case reports of Chilaiditi syndrome in
literature. Chilaiditi syndrome has been known to cause
severe complications including volvulus of the cecum,
splenic flexure or transverse colon, cecal perforation, and
subdiaphragmatic appendicitis perforation3,4
In our case
the patient presented with similar gastrointestinal
symptoms four months back which was first managed
conservatively and not investigated adequately. He had
recurrent symptoms, investigation revealed large
obstructive volvulus and managed with surgical
intervention. Post operative was uneventful. Although a
rare condition, Chilaiditi’s syndrome has important
clinical ramifications. It is a rarely considered differential
diagnosis with vague symptoms that make diagnosis
difficult. Differentials of Chilaiditi syndrome include
bowel obstruction, volvulus, intussusception, ischemic
bowel, appendicitis, and diverticulitis. Even after imaging
is performed, Chilaiditi can still be misinterpreted as
subdiaphragmatic hernia, and pneumoperitoneum. Thus it
is imperative to differentiate this syndrome from the more
serious stimulating pathological condition like perforated
viscus, subphrenic abscess to avoid unnecessary surgical
exploration and proper disposition of the cases5,6
.
CONCLUSION
This case report here will help to sensitise the physician
and the surgeons to keep Chilaiditi Syndrome as a
differential when faced with cases of air under the
diaphragm.
REFERENCES
1. Alva S, Shetty- Alva N, Longo WE. Image of mouth.
Chilaiditi Syndrome. Arch Surg.2008; 143:93-94.
2. Plode JJ, Raker EJ. Transverse colon volvulus and
associated Chilaiditi syndrome: case report and literature
review. Am J Gastroenterol.1996:91:2613-2616
3. Ansari H, Lay J. Chilaiditi Syndrome and associated
caecal volvulus. ANZ J Surg.2011 jun;81 (6):484-5
4. Havenstrite KA, Harris JA, Rivera DE.Splenic flexure
volvulus in association with Chilaiditi syndrome: Report
of a case. Am Surg.1999 Sep;65(9):874-6
5. Vessal K, Borhanmanesh F: Hepatodiaphragmatic
interposition of the intestine Clin Radiol (chilaiditi’s
syndrome) 1976; 27:113-116.
6. Aldoss IT, Abuzetun JY, Nusair M, Suker M, Porter J.
Chilaiditi syndrome complicated by cecal perforation.
Source of Support: None Declared
Conflict of Interest: None Declared