Chilaiditi's syndrome with incarcerated hepatodiaphragmatic small bowel hernia of unknown etiology

May 25, 2007
Kashaf Sherafgan, MD

Surgical Rounds, September 2006, Volume 0, Issue 0

Kashaf Sherafgan, Resident, Department of Surgery, Mount Sinai Hospital, New York, NY; Sergey Khaitov, Resident, Department of Surgery, Mount Sinai Hospital, New York, NY; Fred Silvestri, Assistant Clinical Professor, Department of Surgery, Englewood Hospital & Medical Center, Englewood, NJ

Kashaf Sherafgan, MD

Resident

Department of Surgery

Mount Sinai Hospital

New York, NY

Sergey Khaitov, MD

Resident

Department of Surgery

Mount Sinai Hospital

New York, NY

Fred Silvestri, MD

Assistant Clinical

Professor

Department of Surgery

Englewood Hospital &

Medical Center

Englewood, NJ

In 1910, Demetrius Chilaiditi first described a rare condition in which the bowel is interposed between the liver and diaphragm.1 This finding is often seen incidentally on radiographic studies and misdiagnosed as pneumoperitoneum. We report a case of internal hernia with hepatodiaphragmatic interposition of the small bowel. The hernia contents were incarcerated through the hernia neck, which was formed by adhesions between the liver and the diaphragm, resulting in Chilaiditi's syndrome. This is the second reported case of Chilaiditi's syndrome involving the small bowel2?and the first report where the etiology was unknown.

Case report

A 65-year-old woman with hypertension and no history of abdominal surgery presented to the emergency department reporting severe continuous abdominal pain of 2 days' duration and associated obstipation, nausea, and nonbilious vomiting. She had no recent history of fever but noted a 1-year history of intermittent right upper quadrant pain.

The patient was hemodynamically stable and afebrile. Physical examination showed a soft, mildly distended, tympanitic abdomen, with tenderness to palpation in the right upper quadrant. Her bowel sounds were hypoactive on auscultation and a stool sample was guaiac-negative. A complete blood count showed a leukocyte count of 10,800/mm3?with 81% neutrophils. An abdominal computed tomography (CT) scan showed diffuse small bowel distention to the distal ileum and small bowel loops overlying the liver with punctate foci of gas, which was suspicious of pneumoperitoneum (Figure 1).

A repeat white blood cell count 6 hours later was 18,000/mm3. A presumptive diagnosis of bowel ischemia was made, and the patient was taken to the operating room for diagnostic laparoscopy. Exploration revealed distended loops of small bowel and adhesions between the liver and abdominal wall, which created an internal hernia with small bowel going through the defect and lying above the liver (Figure 2). There was some free fluid above the liver, a sample of which was sent for culture. The bowel was reduced and enterolysis was performed (Figure 3).

By postoperative day 1, the patient's symptoms had resolved, she was tolerating a regular diet, and had normal bowel function. The peritoneal cultures were negative for any bacterial growth, and the patient was discharged from the hospital.

Discussion

In 1910, Demetrius Chilaiditi first described a condition in which the colon or small intestine is interposed either temporarily or permanently between the liver and the diaphragm.1 This anomaly has an estimated prevalence between 0.025% and 0.28% in the general population3 but is more common in men. Only 27 cases have been published in the literature,4 most of which were caused by colonic interposition with hepatodiaphragmatic adhesions from previous abdominal surgeries or sexually transmitted diseases.5 On abdominal radiographs, interposition of the bowel between the liver and diaphragm can be seen as air between the diaphragm and the liver, which is known as Chilaiditi's sign.6?A CT scan can distinguish this condition from pneumoperitoneum by identifying the surrounding bowel wall. Interposition of the bowel between the liver and diaphragm can result in abdominal symptoms ranging from pain to obstructive symptoms, including emesis, distention, and constipation. When these symptoms occur, the condition is termed Chilaiditi's syndrome.

On abdominal radiographs, a diagnosis of pneumoperitoneum is often mistakenly made. Surgical intervention can be avoided if surgeons are aware of the possibility of Chilaiditi's syndrome. Conservative management of this syndrome, including bowel rest, hydration, and nasogastric decompression as needed, is often successful in resolving symptoms. Suspected cases of bowel incarceration or ischemia, however, should be treated with emergent surgical intervention.4

Conclusion

Chilaiditi's syndrome is a rare condition that is usually asymptomatic and is often misdiagnosed as pneumoperitoneum. This clinical entity should be kept in mind by surgeons and radiologists so that unnecessary surgical intervention can be avoided. Although Chilaiditi's syndrome is generally associated with colonic interposition, our case involved interposition of the small bowel, which resulted in acute intestinal obstruction. Loops of jejunum were trapped above the liver due to adhesions, with no known cause. This is the second reported case of small bowel interposition causing Chilaiditi's syndrome and the first of unknown etiology, because our patient had no previous abdominal surgeries or sexually transmitted diseases.

References

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2. Risaliti A, De Anna D, Terrosu G, et al. Chilaiditi's syndrome as a surgical and nonsurgical problem. 1993; 176(1):55-58.

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3. Orangio GR, Fazio VW, Winkelman E, et al. The Chilaiditi syndrome and associated volvulus of the transverse colon. An indication for surgical therapy. 1986; 29(10):653-656.

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4. Saber AA, Boros MJ. Chilaiditi's syndrome: what should every surgeon know? 2005; 71(3):261-263.

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5. Oh SN, Rha SE, Byun JY, et al. Chilaiditi syndrome caused by Fitz-Hugh-Curtis syndrome: multidetector CT findings. 2006; 31(1):45-47.

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6. Plorde JJ, Raker EJ. Transverse colon volvulus and associated Chilaiditi's syndrome: case report and literature review. 1996; 91(12):2613-2616.

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