Chilaiditi syndrome

Last revised by Mostafa Elfeky on 24 Dec 2021

Chilaiditi syndrome is the anterior interposition of the colon to the liver reaching the under-surface of the right hemidiaphragm with associated upper abdominal pain; it is one of the causes of pseudopneumoperitoneum.

Colonic gas in this position may be misinterpreted as true pneumoperitoneum resulting in further imaging, investigation, and treatment that is not required.

Pain distinguishes Chilaiditi syndrome from asymptomatic colonic interposition, which is termed as Chilaiditi sign. This is by virtue of the fact that syndrome is a collection of signs and symptoms.

Chilaiditi sign is most commonly seen in the elderly with an incidence of ~ 1% worldwide and has a male predilection of 4:1 5.

Patients with Chilaiditi syndrome generally present with abdominal pain, anorexia, nausea, vomiting, constipation or changes in bowel habits. As the degree of colonic interposition increases patients may develop respiratory distress 5. Symptoms are generally worse at night when laying supine 5.

Suspensory ligaments and fixation of the colon normally prevents interposition of the colon between the liver and diaphragm. Predisposing factors to Chilaiditi syndrome include 5:

  • congenital malposition
  • chronic constipation
  • cirrhosis or hepatectomy
  • ascites with increased intra-abdominal pressure
  • diaphragmatic paralysis 
  • multiparous women 

Features that suggest a Chilaiditi syndrome (i.e. Chilaiditi sign) include:

  • gas between the liver and diaphragm
  • haustra within the gas suggesting that it is within the bowel and not free

If there is a clinical suspicion of abdominal visceral perforation and plain radiographic appearances are unclear, abdominal CT can be performed to clarify whether there is pneumoperitoneum.

CT can clearly demonstrate the presence of interposed colonic loops between the right hemidiaphragm and liver with no free intraperitoneal air. 

Asymptomatic patients with Chilaiditi sign do not require specific treatment. Those with Chilaiditi syndrome presenting with abdominal pain or distension are usually treated conservatively with analgesia, fluid resuscitation and aperients. Patients with recurrent presentations or evidence of bowel ischemia may be offered surgical treatment. Gangrenous or ischemic bowel segments may have to be removed if there is associated colonic volvulus. Otherwise, colopexy may be sufficient to prevent future recurrence of symptoms.

It is named after Demetrius Chilaiditi (1883-1975) 4, Greek radiologist who described the radiographic findings in 1910 3 whilst working in Vienna, Austria. Although the first description of the interposition of colon between the liver and the right hemidiaphragm was published by Cantini in 1865 4.

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