Resident The Christ Hospital Health Network, United States
Introduction: Chilaiditi sign is a benign finding seen on radiographic imaging when the bowel becomes interposed between the right hemidiaphragm and liver, occasionally showing visible haustra. Chilaiditi syndrome is the clinical manifestation consisting of abdominal pain and other gastrointestinal symptoms, respiratory distress, or cardiac symptoms that may be worse at night. There is approximately a 1% incidence that increases with age and male gender. Diagnosis of Chilaiditi sign requires 3 radiologic findings: the right hemidiaphragm must be elevated above the liver by the intestine, the bowel must be distended with air to show pseudo-pneumoperitoneum, and the superior margin of the liver must be depressed below the level of the left hemidiaphragm. Asymptomatic patients are treated conservatively once pneumoperitoneum is ruled out. Symptomatic patients can be treated conservatively, with repeat imaging to monitor resolution. Surgery may be indicated if the patient is unresponsive to conservative management, obstruction does not resolve, or if there is evidence of bowel ischemia.
Description: An 85 year-old male with past medical history significant for Alzheimer disease, coronary artery disease, aortic stenosis, hypertension, bladder and prostate cancer who presented with shortness of breath post-op day 4 status post left femoral-popliteal bypass for repair of left popliteal artery aneurysm. Chest X-ray (CXR) on 6/30/24 with some concern for pneumoperitoneum. Case was discussed with the radiologist who read the study and confirmed Chilaiditi sign. Further chart review revealed chest computed tomography (CT) on 6/12/24 that showed colon between the liver and the right hemidiaphragm. Pseudo-pneumoperitoneum resolved on CXR on 7/3/24. Given patient was asymptomatic, no acute intervention was indicated. Patient’s dyspnea was likely caused by postoperative pulmonary insufficiency and atelectasis. Hospital course was further complicated by delirium, AFib with RVR, ESBL UTI, and hypotension.
Discussion: Mistaking bowel gas for free air can drastically alter patient management and add to the problem of unnecessary healthcare expenditure. This case demonstrates the importance of clinical correlation between radiographic findings and patient symptomatology in addition to multidisciplinary communication.
