La tunisie Medicale - 2017 ; Vol 95 ( n°01 ) :
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Article

An 89-year-old man, suffering from arterial hypertension, was presented to our unit with a history of epigastric pain, vomiting and appetite loss. The physical examination was unremarkable. Routine laboratory tests showed an inflammatory anemia. The upper gastrointestinal endoscopy found a large duodenal ulcer. A systematic chest-x-ray revealed the presence of a subphrenic interposition of the colon above the liver. A computed tomography scan confirmed this sign. Combination of two antibiotics (clarithromycin and amoxicillin) and proton pump inhibitors were prescribed and the patient was discharged from hospital asymptomatic.

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Chilaiditi’s sign(or syndrome) is a rare condition with an incidence of 0.025-0.28% in abdominal or chest radiographs. Predisposing factors include dolichocolon, atrophic liver or ptotic liver making patients more prone to colonic volvulus. Presentation is generally asymptomatic and is mostly diagnosed as an incidental finding (Chilaiditi’s sign). However, symptoms ranging from nonspecific intermittent mild abdominal pain to acute intestinal volvulus were also reported. The syndrome is important because it can simulate pneumoperitoneum radiologically. Abdominal computed tomography may be required to exclude the presence of pneumoperitoneum in some cases.Diagnosis of both the sign and syndrome is dependent on radiological evidence. Three findings are key on radiographs. First, the right hemidiaphragm must be adequately elevated by the bowel above the liver. Second, the bowel must be distensed by air to visualize the pseudo-pneumoperitoneum. Third, the liver must be depressed to the extent that the superior margin is below the level of the left hemidiaphragm. Also, changing the position of a patient with Chilaiditi’s will not change the position of the radiolucency, unlike a patient with free air. If it is unclear whether the subdiaphragmaticair is free or intraluminal, abdominal computed tomography is recommended to establish a definitive diagnosis. Treatment of Chilaiditi’s syndrome includes non-operative approaches (bed rest, fluid supplementation,nasogastric decompression, enemas and stool softeners). However, 26% of patients may require colectomy. Alternatively, laparoscopic colopexy has been described.In conclusion, Chilaiditi’s sign and syndrome are important differential diagnoses for general surgeons. One should be aware of the radiological evidence of pneumoperitoneum and pseudo-pneumoperitoneum. Such awareness could result in decreased incidence of unnecessary exploratory laparotomies for misdiagnosed pneumoperitoneum.

Fig.1. Chest radiograph showing the Cilaiditi’s sign.

 Fig.2. Computed tomography showing the colonic interposition above the liver dome.

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