Ann Thorac Surg 2009;87:959-961. doi:10.1016/j.athoracsur.2008.07.033
© 2009 The Society of Thoracic Surgeons
Case Reports
Chilaiditi's Sign Mimicking a Traumatic Diaphragmatic Hernia
Mitsuhiro Kamiyoshihara, MD, PhDa,*,
Takashi Ibe, MDa,
Izumi Takeyoshi, MD, PhDb
a Department of General Thoracic Surgery, Maebashi Red Cross Hospital, Maebashi, Gunma, Japan
b Division of Thoracic and Visceral Organ Surgery, Gunma University Graduate School of Medicine, Maebashi, Gunma, Japan
Accepted for publication July 9, 2008.
* Address correspondence to Dr Kamiyoshihara, Department of General Thoracic Surgery, Maebashi Red Cross Hospital, 3-21-36 Asahi-Cho, Maebashi, Gunma, 371-0014, Japan (Email: micha2005jp{at}yahoo.co.jp).
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Abstract
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A 75-year-old man had bruising develop after a traffic accident. A chest roentgenogram revealed elevation of the right hemidiaphragm. A subsequent computed tomographic scan showed interposition of the colon between the liver and diaphragm in front of the liver. Initially, we suspected a traumatic diaphragmatic hernia. Urgent exploratory video-assisted thoracoscopic surgery showed no injury of the right diaphragm. With the benefit of hindsight, there was no rupture of the diaphragm on the image. Hepato-diaphragmatic interposition of the colon is a very rare anomaly. This case was "Chilaiditi's sign" mimicking a traumatic diaphragmatic hernia.
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Introduction
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Physicians engaged in critical care must address a wide variety of different types of trauma and disease and will occasionally encounter unanticipated cases. Chilaiditi's sign is an anomaly in which the bowel is interposed between the liver and right hemidiaphragm. This anomaly, which was first described by Chilaiditi [1], occurs in 0.025% to 0.28% of the general population [2], and it is rarely presented in case studies or imaging reports, which are usually published in journals on gastroenterological medicine [2–5]. However, thoracic surgeons should be aware of Chilaiditi's sign, because it may cause overestimation of the degree of trauma. Chilaiditi's sign must be distinguished from Morgagni's hernia, subdiaphragmatic abscess, and pneumoperitoneum. In this case, Chilaiditi's syndrome mimicked a traumatic diaphragmatic hernia. We believe that this is the first report of Chilaiditi's sign misinterpreted as damage due to chest trauma.
A 75-year-old man had bruising on the right side of the hypochondrium that developed after a traffic accident, and he was immediately transferred to our hospital by ambulance. The patient complained of severe pain in the bruised area. The patient had no relevant medical or surgical history and no chest symptoms since birth. There was no relevant family history. There were no previous chest roentgenograms. A chest roentgenogram revealed elevation of the right hemidiaphragm (Fig 1). A subsequent computed tomographic (CT) scan showed interposition of the colon between the liver and diaphragm in front of the liver (Fig 2). Initially, we suspected a traumatic diaphragmatic hernia and planned urgent exploratory video-assisted thoracoscopic surgery. The patient was placed in the left lateral decubitus position, and a working port measuring 10 cm in length was made in the eighth intercostal space. Additional thoracic ports were made in the sixth intercostal space in the anterior axillary line. The operative findings showed no injury of the diaphragm, lung, or other thoracic organs. We concluded that the right diaphragm was elevated on the images only. With the benefit of hindsight, a CT scan demonstrated successive cross-sections and no rupture of the diaphragm. The right lobe of the liver was partially hypoplastic. Subsequently, the patient required treatment for a brain contusion and a right elbow fracture by an orthopedic surgeon. Ultimately, he made a full recovery and was discharged on day 22 after surgery.
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Fig 2. A subsequent computed tomographic scan showed interposition of the colon between the liver and the diaphragm in front of the liver. (A,B = coronal section; C,D = sagittal section.)
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Comment
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Usually Chilaiditi's sign is asymptomatic and is only a radiographic finding [6]. The interposed bowel is usually the proximal transverse colon or rarely the small intestine. The best way to visualize Chilaiditi's sign is to use CT, especially in coronal and sagittal sections.
The cause of Chilaiditi's sign remains unknown. However, we hypothesize that this anomaly has many possible causes. The colon is stabilized by the colonic suspensory ligaments, mesocolon, liver and its falciform ligament, and normal anatomical arrangement of the surrounding organs [7]. When some of these factors fail, colonic interposition occurs. Some previous reports have indicated that the anomaly frequently accompanies anatomical variations, including (1) absence of the suspensory ligaments of the transverse colon and falciform ligament of the liver, (2) redundant colon, (3) right diaphragmatic paralysis or eventration, and (4) enlargement of the thorax leaving extra space for potential colon migration [4, 5].
With regard to the cause in our case, we postulate that there was a congenital defect of the ligaments, but this remains speculative as we did not explore the abdomen. Why was the diaphragm elevated? A high position of the diaphragm can result from eventration, phrenic nerve palsy, or injury. It is unlikely that this traffic accident resulted in phrenic nerve palsy, because the resulting interposition of the colon could not occur so early. It is possible that the right lobe of the liver was partially hypoplastic, and the transverse colon seemed to pass through the space between the diaphragm and liver on CT. In this case, the hypoplastic liver may have allowed interposition of the colon and subsequent diaphragmatic elevation.
A "sign" does not require treatment. However, treatment is occasionally required in cases with symptoms, such as abdominal pain, constipation, vomiting, respiratory distress, anorexia, and rarely volvulus or obstruction. Such cases are referred to as Chilaiditi's syndrome and not Chilaiditi's sign. The treatment of Chilaiditi's syndrome is usually nonsurgical and includes bed rest, fluid supplementation, nasogastric decompression, enemas, cathartics, a high-fiber diet, and stool softeners. Orangio and colleagues [4] reported that Chilaiditi's sign was associated with colonic volvulus, observing the rare progression of colonic interposition from mild abdominal discomfort to intermittent bowel obstruction requiring surgical intervention. Surgical treatment, such as colectomy [6], colopexy [8], and hepatopexy [5], may also be required in rare cases.
As our patient was asymptomatic in terms of Chilaiditi's sign, this was not specifically treated. Here, we present a case of Chilaiditi's sign found incidentally in blunt chest trauma. General thoracic and traumatic surgeons should consider Chilaiditi's sign or syndrome to avoid unnecessary surgical intervention.
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References
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- Chilaiditi D. Zur Frage der Hapatoptose und Ptose in allemeinen im Auschluss an drei Falle von temporaerer partiellaer LeververlagerungMunich, Germany: Fortschritte auf dem Gebiete der Roentgenstrahlen; 1910. pp. 173-20816.
- Bassan MS, Thomson A. Education and imaging. Gastrointestinal: Chilaiditi syndrome. J Gastroenterol Hepatol 2008;23:499.[Medline]
- Alva S, Shetty-Alva N, Longo WE. Image of the month. Chilaiditi sign or syndrome. Arch Surg 2008;143:93-94.[Free Full Text]
- Orangio GR, Fazio VW, Winkelman E, McGonagle BA. The Chilaiditi syndrome and associated volvulus of the transverse colon: an indication for surgical therapy Dis Colon Rectum 1986;29:653-656.[Medline]
- Risaliti A, De Anna D, Terrosu G, Uzzau A, Carcoforo P, Bresadola F. Chilaiditi's syndrome as a surgical and nonsurgical problem Surg Gynecol Obstet 1993;176:55-58.[Medline]
- Saber AA, Boros MJ. Chilaiditi's syndrome: what should every surgeon know? Am Surg 2005;7:261-263.
- Agur AMR. The AbdomenIn: Agur AMR, Lee MJ, editors. Grant's atlas of anatomy. 9th edit.. Baltimore, MD: Williams & Wilkins; 1991. pp. 77-146.
- Lohr CE, Nuss MA, McFadden DW, Hogg JP. Laparoscopic management of Chilaiditi's syndrome Surg Endosc 2004;18:348.[Medline]
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Abstract
Introduction
