Chilaiditi’s sign, a cause of pseudo-pneumoperitoneum: A case report

Abstract

The differentiation between a pseudo-pneumoperitoneum and true pneumoperitoneum on an initial chest radiograph is challenging but essential to clinical practice. The former is managed conservatively whereas the latter may require surgical intervention. Chilaiditi’s sign describes a rare incidental radiological finding of gas filled bowel interpositioned between the right hemi-diaphragm and the liver, which is visible on a plain abdominal or chest radiograph. It is often misdiagnosed as a pneumoperitoneum. Correct diagnosis of Chilaiditi’s sign in an asymptomatic patient can prevent unnecessary procedures. We have reported one incidental chest radiograph with Chilaiditi’s sign in a patient presenting and treated for pneumonia. The report aims to illustrate the diagnostic dilemma experienced by clinicians in distinguishing a true versus pseudo-pneumoperitoneum on a chest radiograph.

Pneumoperitoneum and Chilaiditi syndrome: navigating a diagnostic conundrum

“…This sign can be mistaken with a pneumoperitoneum, which signifies the presence of a perforated intra-abdominal bowel, particularly if accompanied by signs such as abdominal tenderness and guarding. Conversely, a pseudo-pneumoperitoneum describes the presence of intra-peritoneal air which appears as free, but in reality, it is contained within an organ [ 1 , 8 ].…”

“…It is often considered as a fortuitous radiological finding, which is visible on a plain abdominal or chest X ray. It is a radiological manifestation of a gas filled bowel’s interposition between the right hemi-diaphragm and the liver, which can mistakenly be confused with pneumoperitoneum [ 1 ]. Its incidence is that of 0.3% for chest X-rays and 2.4% for CT-scans [ 2 ].…”

An Uncommon Cause of Palpitations

“…Chilaiditi syndrome is an uncommon condition, being described in 0.025%-0.28% of the population [1] An 18-year-old female, with no relevant personal history or usual medication is admitted at the emergency department with complaints of palpitations and mild abdominal pain. On physical examination, she is hemodynamically stable, sinus tachycardia with HR of 126 bpm and abdominal pain discomfort in palpation, without signs of peritoneal irritation.…”

“…Elevation of the right hemidiaphragm occurs, the colon (identified by the presence of haustra) is interposed between the diaphragm and the liver. The superior hepatic border is positioned inferior to the left diaphragm [1].…”

“…In most patients, the interposition of a portion of the colon between the liver and the diaphragm is asymptomatic and is often an incidental finding, denominated as the Chilaiditi sign [1]. However, Chilaiditi syndrome is accompanied by symptoms related to the digestive system, namely nausea, dyspepsia, constipation, abdominal pain, or intestinal obstruction secondary to intestinal volvulus [2].…”