Chilaiditi ' s sign and syndrome : theoretical facts and a case report Chilaiditi-jev znak i sindrom

Introduction. Chilaiditi's syndrome is a rare condition manifested by gastrointestinal symptoms, and radiologically verified by transposition of the large intestine loop. This radiological finding with no manifested symptoms is termed the Chilaiditi's sign. The aim of this case report was to remind the clinicians of the possibility of this rare syndrome, whose symptoms and signs may be misinterpreted and inadequately treated, with consequent diverse complications. Case report. We presented the theoretical facts and a patient in whom the diagnosis of Chilaiditi's syndrome was established incidentally, when hospitalized for an exacerbation of his chronic obstructive pulmonary disease. The Chilaiditi's sign was verified as an incidental finding on chest X-ray performed to evaluate the primary disease. Conclusion. Chilaiditi's syndrome is a benign condition which rarely requires surgery. Its clinical importance lies in adequate differential diagnostic approach and timely management of potentially serious complications.


Case report
A old-75-year patient, was admitted to the Institute for Pulmonary Diseases of Vojvodina, Sremska Kamenica, Serbia, due to exacerbation of his chronic obstructive pulmonary disease, outpatiently treated for over twenty years.Having responded poorly to the intensified ambulatory desobstruction treatment, the patient was referred to hospital.He was presented with a variety of comorbidities, including arterial hypertension, atrial fibrillation, valve defect, abdominal her- nia, cholelithiasis, prostatic hyperplasia, degenerative spinal disease, depression.The patient complained on the symptoms of cough, dyspnea, fatigue, heart palpitations and arrhythmia, occasional pains below the right rib arch, and dyspeptic problems.On admission, the patient was conscious, oriented, exhausted, moving with difficulties, afebrile, dyspnoic, normocardic, normotensive, with no signs of cardiac decompensation, giving the impression of a moderately severe patient.On auscultation, bronchospasm signs were registered.The abdomen was at the level of the chest, soft on palpation, with a reponible hernia of the anterior abdominal wall, and a mildly painful, sensitive epigastric region, audible peristalsis, and no signs of meteorism or ascites.The chest X-ray finding was presented with bilateral striped paracardial lesions, adhering hemidiaphragms, and the presence of an air collection below the right hemidiaphragm (Figure 1).The pulmonary gas exchange at rest was preserved, and bronchoobstruction was verified on spirometry.Standard laboratory test findings were within normal ranges.The bacteriological sputum finding was normal as well.Computed tomography (CT) of the chest excluded the presence of infiltrative lesions in the pulmonary parenchyma, verified bilateral bronchiectases, bilateral excrescences in the basal pleura, degenerative spinal lesions, and the Chilaiditi's sign (Figure 2).

Fig. 2 -Computed tomography of the chest verified the Chilaiditi's sign (arrow).
Echocardiography verified ejection fraction of 50%, paradoxical septal movements, initial concentric hypertrophy of the left ventricle myocardium, sclerosis of aortic valves, mitral regurgitation 3+.The treatment included inhalant and parenteral desobstructive therapy, gastroprotective medication, peroral anticoagulant therapy and other formerly prescribed cardiological therapy.The gastroenterologist was consulted, who recommended conservative treatment measures and advised to consult the abdominal surgeon in case of an acute exacerbation of gastrointestinal symptoms.The applied treatment improved the patient's general and respiratory condition, and he was discharged with recommendations for further ambulatory treatment, and instructed what to do in case of exacerbated respiratory and gastrointestinal symptoms.

Discussion
Chilaiditi's sign is an incidental radiological finding, presented as a crescent lucency below the diaphragm on the right, occurring due to malpositioned loops of the colon and/or small intestine. 5It was for the first time described by Cantini in 1865 but the first three case reports were published by the Greek radiologist Demetrius Chilaiditi in 1910, after whom this condition has been named 2,3 .Its incidence ranges from 0.025% to 0.028% 3 .In males and the elderly, it is registered four times as frequently as in other population groups, the incidence amounting to around 1% 3,4 .Being an asymptomatic condition, its diagnosis is established incidentally, on the occasion of different radiological examinations of the chest or abdomen (CT, standard chest X-ray, or ultrasound) 7 .
Predisposing factors include all the conditions resulting in the increased right subphrenic space or intestinal hypermobility.These factors may be classified as congenital or acquired (Table 1) 1, 5, 7-9 , diaphragmatic, intestinal, hepatic, and others (Table 2) 4 .

Table 1
Congenital and acquired predisposing factors for Chilaiditi's sign and syndrome

COPD -chronic obstructive pulmonary disease.
The diagnosis is established on the basis of the chest Xray finding presented with the following three features 5,7 : elevation of the right hemidiaphragm; a crescent lucency be-  Most frequently, there is a malposition of the hepatic flexure of the colon, ascending or transversal colon, more rarely of the cecum, independently or in combination with the small intestine 4 .Depending on the position of the intestines in relation to the liver, the anterior and posterior type are differentiated 4 , which may be either temporary or permanent 6, 7, 9 .
Chilaiditi's sign is easily diagnosed, analyzing the standard chest X-ray finding.CT is the imaging technique of choice here, as it concurrently excludes a rupture of the diaphragm, intestinal perforation, congenital malformations, as well as other conditions and diseases [7][8][9] .The differential diagnosis includes renal or biliary colics, subphrenic abscess, pneumoperitoneum, or congenital diaphragmatic hernias 1,[5][6][7] .The most important radiologic indicators excluding these serious complications, particularly pneumoperitoneum, are the presence of the intestinal haustrum and the persisting pseudoperitoneum position at changing bodily postures.
The timely diagnosis is important to prevent the complications which may arise while performing various diagnostic pro-cedures, including percutaneous liver biopsy, pleural puncture, and colonoscopy 4,5 .
Chilaiditi's syndrome is a rare condition manifested by diverse gastrointestinal symptoms, and a radiologically verified Chilaiditi's sign.It occurs very rarely, in elderly males four times as frequently as in elderly females, and the cases in children have also been reported 4 .It is manifested by the symptoms differing in intensity and frequency -abdominal pains, flatulence and "pouring" in the bowel, nausea, vomiting, altered discharge habits, more rarely retrosternal pains, heart arrhythmia, dyspnea, and respiratory distress 4,5 .Different diseases and conditions may be additionally prolonged if accompanied with this syndrome; these most often include chronic obstructive pulmonary disease, sclerodermia, congenital hypothyroidism, paralytic ileus, melanosis coli, mental retardation, more rarely lung and colon cancer, bariatric surgery, gastric probe placement, colonoscopy 4 .
The treatment of the syndrome is initiated by conservative measures including rest, rehydration, high content of plant fibers in the diet, nasogastric decompression, laxatives and/or antiemetics 7 .If the conservative treatment fails to result in adequate clinical and/or radiologic improvement or obstruction, ischemia or perforation are suspected, surgical treatment should be carried out 4,7 .Cases requiring urgent surgery were rarely reported in the literature, which included volvulus of the cecum or colon, subphrenic appendicitis, intestinal perforation, intraabdominal herniation 4,9 .No unique attitude to the most adequate surgical approach has been formulated yet.Invasive surgeries, including colon resection, hepatopexy, colonopexy, right hemicolectomy, sigmoidectomy, and subtotal colectomy have been successfully carried out, as well as less invasive laparoscopic colonopexies 4,7,9 .

Conclusion
Chilaiditi's syndrome is a benign condition which rarely requires surgery.The clinical relevance of Chilaiditi's syndrome lies in the possibility to recognize and prevent various complications causing acute abdominal symptoms, such as obstruction, perforation or ischemia of the intestines.

Fig. 1 -
Fig. 1 -The chest x-ray reveals air collection below the right hemidiaphragm.