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Special Feature |

Image of the Month—Diagnosis FREE

[+] Author Affiliations

Section Editor: Grace S. Rozycki, MD, MBA

More Author Information
Arch Surg. 2008;143(1):94. doi:10.1001/archsurg.2007.12-b.
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Chilaiditi sign refers to the usually asymptomatic interposition of the bowel (usually the hepatic flexure of the colon) between the liver and the right hemidiaphragm. It was first described by a Viennese radiologist, Demetrius Chilaiditi, in 1910.1This phenomenon is seen in 0.025% to 0.28% of the general population.2The findings are most often incidental; the condition is slightly more common in males, adults, and individuals with cognitive impairment; and symptoms may present intermittently3. The term signrefers to the asymptomatic presence of the interposed bowel, whereas the term syndromeincludes abdominal pain, constipation, vomiting, respiratory distress, anorexia, and rarely, volvulus or obstruction.

Colonic fixation and suspensory ligaments, coupled with the normal anatomy of the diaphragm and the liver, normally inhibit this potential interposition.2,47Predisposing factors to its occurrence include absence of the normal suspensory ligaments of the transverse colon, abnormality or absence of the falciform ligament, redundant colon (as might be seen with chronic constipation or bedridden individuals), excessive aerophagia in children (secondary to increased colonic air), right hemidiaphragm elevation (paralysis or eventration), an enlarged thoracic cage in emphysema (leaving extra space for potential colon migration), congenital malposition or malrotation (leading to increased colonic mobility), ascites (the “floating liver” of ascites can be more easily displaced by the adjacent hepatic flexure), or multiple pregnancies.5,6,8,9

Treatment of Chilaiditi syndrome includes nonoperative approaches (bed rest, fluid supplementation, nasogastric decompression, enemas, cathartics, high-fiber diets, and stool softeners). However, 26% of patients may require colectomy.3,10,11Alternatively, laparoscopic colopexy has been described.12

In conclusion, recognition of Chilaiditi syndrome and its spectrum is important because if this entity is mistaken for a more serious abnormality (pneumoperitoneum, subphrenic abscess, ruptured abdominal viscus, posterior hepatic lesions, or retroperitoneal masses), unnecessary surgical intervention may result.

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Submissions

Due to the overwhelmingly positive response to the Image of the Month, the Archives of Surgeryhas temporarily discontinued accepting submissions for this feature. It is anticipated that requests for submissions will resume in mid-2008. Thank you.

Correspondence:Walter E. Longo, MD, Department of Surgery, Yale University School of Medicine, PO Box 208062, New Haven, CT 06520-8062 (walter.longo@yale.edu).

Accepted for Publication:August 26, 2007.

Author Contributions:Acquisition of data: Shetty-Alva. Analysis and interpretation of data: Alva and Longo. Drafting of the manuscript: Alva. Critical revision of the manuscript for important intellectual content: Longo. Administrative, technical, and material support: Alva and Shetty-Alva. Study supervision: Longo.

Financial Disclosure:None reported.

Chilaiditi  D Zur Frage der Hapatoptose und Ptose in allemeinen im Auschluss an drei Falle von temporaerer partiellaer Leberverlagerung.  Munich, Germany Fortschritte auf dem Gebiete der Roentgenstrahlen1910;173- 208
Orangio  GRFazio  VWWinkelman  EMcGonagle  BA The Chilaiditi syndrome and associated volvulus of the transverse colon: an indication for surgical therapy. Dis Colon Rectum 1986;29 (10) 653- 656
PubMed Link to Article
Saber  AABoros  MJ Chilaiditi's syndrome: what should every surgeon know? Am Surg 2005;71 (3) 261- 263
PubMed
Isbister  WHBellamy  P Hepato-diaphragmatic interposition of the intestine (Chilaiditi's syndrome): a case report. Aust N Z J Surg 1991;61 (6) 462- 464
PubMed Link to Article
Walsh  SDCruikshank  JG Chilaiditi syndrome. Age Ageing 1977;6 (1) 51- 57
PubMed Link to Article
Vessal  KBorhanmanesh  F Hepatodiaphragmatic interposition of the intestine (Chilaiditi's syndrome). Clin Radiol 1976;27 (1) 113- 116
PubMed Link to Article
Risaliti  ADe Anna  DTerrosu  GUzzau  ACarcoforo  PBresadola  F Chilaiditi's syndrome as a surgical and nonsurgical problem. Surg Gynecol Obstet 1993;176 (1) 55- 58
PubMed
Javors  BRSorkin  NSFlint  GW Transverse colon volvulus: a case report. Am J Gastroenterol 1986;81 (8) 708- 710
PubMed
Gumbs  MAKashan  FShumofsky  EYerubandi  SR Volvulus of the transverse colon: reports of cases and review of the literature. Dis Colon Rectum 1983;26 (12) 825- 828
PubMed Link to Article
Siraj  QHMcGlone  BS Chilaiditi's syndrome on Tc-99m hexamethylpropylene amineoxime imaging. Clin Nucl Med 1999;24 (9) 699- 700
PubMed Link to Article
Rompen  JCZeebregts  CJPrevo  RLKlaase  JM Incarcerated transdiaphragmatic intercostal hernia preceded by Chilaiditi's syndrome. Hernia 2005;9 (2) 198- 200
PubMed Link to Article
Lohr  CENuss  MAMcFadden  DWHogg  JP Laparoscopic management of Chilaiditi's syndrome. Surg Endosc 2004;18 (2) 348
PubMed Link to Article

Figures

Tables

References

Chilaiditi  D Zur Frage der Hapatoptose und Ptose in allemeinen im Auschluss an drei Falle von temporaerer partiellaer Leberverlagerung.  Munich, Germany Fortschritte auf dem Gebiete der Roentgenstrahlen1910;173- 208
Orangio  GRFazio  VWWinkelman  EMcGonagle  BA The Chilaiditi syndrome and associated volvulus of the transverse colon: an indication for surgical therapy. Dis Colon Rectum 1986;29 (10) 653- 656
PubMed Link to Article
Saber  AABoros  MJ Chilaiditi's syndrome: what should every surgeon know? Am Surg 2005;71 (3) 261- 263
PubMed
Isbister  WHBellamy  P Hepato-diaphragmatic interposition of the intestine (Chilaiditi's syndrome): a case report. Aust N Z J Surg 1991;61 (6) 462- 464
PubMed Link to Article
Walsh  SDCruikshank  JG Chilaiditi syndrome. Age Ageing 1977;6 (1) 51- 57
PubMed Link to Article
Vessal  KBorhanmanesh  F Hepatodiaphragmatic interposition of the intestine (Chilaiditi's syndrome). Clin Radiol 1976;27 (1) 113- 116
PubMed Link to Article
Risaliti  ADe Anna  DTerrosu  GUzzau  ACarcoforo  PBresadola  F Chilaiditi's syndrome as a surgical and nonsurgical problem. Surg Gynecol Obstet 1993;176 (1) 55- 58
PubMed
Javors  BRSorkin  NSFlint  GW Transverse colon volvulus: a case report. Am J Gastroenterol 1986;81 (8) 708- 710
PubMed
Gumbs  MAKashan  FShumofsky  EYerubandi  SR Volvulus of the transverse colon: reports of cases and review of the literature. Dis Colon Rectum 1983;26 (12) 825- 828
PubMed Link to Article
Siraj  QHMcGlone  BS Chilaiditi's syndrome on Tc-99m hexamethylpropylene amineoxime imaging. Clin Nucl Med 1999;24 (9) 699- 700
PubMed Link to Article
Rompen  JCZeebregts  CJPrevo  RLKlaase  JM Incarcerated transdiaphragmatic intercostal hernia preceded by Chilaiditi's syndrome. Hernia 2005;9 (2) 198- 200
PubMed Link to Article
Lohr  CENuss  MAMcFadden  DWHogg  JP Laparoscopic management of Chilaiditi's syndrome. Surg Endosc 2004;18 (2) 348
PubMed Link to Article

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