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Special Feature
January 1, 2008

Image of the Month—Diagnosis

Arch Surg. 2008;143(1):94. doi:10.1001/archsurg.2007.12-b
Answer: Chilaiditi Sign or Syndrome

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.

Box Section Ref ID


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.

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