Aaisha Khan, Sarmad Waqas
Post Graduate Trainee, Mayo Hospital, Lahore, Pakistan

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Case Scenario

Questions

1. Describe the radiological sign shown in the [Figure 1]?
2. What is the difference between the associated sign and the syndrome?
3. Name a few conditions associated with this sign?
4. How will this patient be managed?

Answers

1. This chest X-ray (anteroposterior view) shows interposition of the small bowel between the liver and the right hemidiaphragm, and radiologically this term is called Chilaiditi's sign. ^[1] It was first described by Demetrious Chilaiditi in 1910, ^[2] who discovered 3 cases of hepatodiaphragmatic interposition (HDI). Since then it is known as Chilaiditi's sign. ^[1] Chilaiditi's sign is generally an incidental, asymptomatic radiographic finding. ^[1] It may remain undiagnosed throughout ones lifetime. ^[3] Chilaiditi's sign is recognized on plain X-ray chest by air collection marking with haustral signs in the subdiphragmatic area. If in doubt, CT chest with contrast can differentiate a subdiaphragmatic abscess from it. ^[3]
2. Chilaiditi's sign is an x-ray finding of hepatodiaphragmatic interposition. However, in some people, it is associated with symptoms such as nausea, abdominal pain, vomiting, distention, flatulence, substernal pain, incomplete intestinal obstruction, cardiac arrhythmias or dyspnea. ^[3] If symptomatic, this radiographic term is called Chilaiditi's sign. ^[2]
3. Chilaiditi's sign is noted in many disorders including liver cirrhosis, chronic obstructive lung disease, near-term pregnancy, mental disorders and obesity. Chilaiditi's syndrome has been reported with colonic volvulus, suprahepatic appendicitis, scleroderma, congenital hypothyroidism, melanosis coli and  Salmonellosis ^{More Details}. A few articles mention Chilaiditi's syndrome with breast, colonic, gastric and lung carcinoma. ^[3]
4. Mostly symptoms resolve by bed rest and conservative management. If symptoms progress, patient should be referred to surgery. ^[3]

References

1.	Nakagawa H, Toda N, Taniguchi M, Ibukuro K, Tagawa K. Prevalence and Sonographic Detection of Chilaiditi's sign in Cirrhotic Patients Without Ascites. AJR 2006;187:W589-93.
2.	Glatter RD, April RS, Miskovitz P, Neistadt LD. Severe Recurrent Abdominal Pain: An Abdominal Variant of Chilaiditi's Syndrome. MedGenMed 2007;9:67.
3.	Demirbas S, Kurt Y, Akin ML, Ozturk A, Celenk T. Chilaiditi's syndrome with pancreatic malignancy. Turkjcancer 2007;37:117-9.

Correspondence Address:
Aaisha Khan
99- BB, Phase 4, Defence Housing Authority, Lahore
Pakistan

Source of Support: None, Conflict of Interest: None

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DOI: 10.4103/1319-3767.56088