Medical Image of the Week: Chilaiditi Syndrome

Figure 1. An X-ray of the chest showing a lucency under the right hemi-diaphragm interposed between the liver and diaphragm (arrow).

Figure 2. CT scan of the chest showing gas filled distended hepatic flexure interposed between the elevated right hemi-diaphragm and the liver (arrow).

X-ray evidence of air under right hemi-diaphragm in proper clinical context is almost a definitive sign of gastrointestinal tract perforation except in an extremely rare clinical entity called "Chilaiditi Syndrome". We present this unique image and clinical scenario to expand on physician`s knowledge to identify this rare clinical syndrome and to help distinguish it from a dreaded condition like gastrointestinal perforation.

An 81-year-old man with multiple co-morbidities was admitted to the intensive care unit with a diagnosis of acute hypoxic respiratory failure. An X-ray of the chest showed a lucency under the right hemi-diaphragm interposed between the liver and diaphragm (Figure 1). Due to radiological concern of gastrointestinal perforation, an emergent CT scan was performed to rule out perforation. CT scan revealed gas filled distended hepatic flexure interposed between the elevated right hemi-diaphragm and the liver (Figure 2). The patient had no gastro-intestinal tract symptoms and no pathological signs were specifically identified on clinical examination; a diagnosis of the Chilaiditi Syndrome was made. Chilaiditi Syndrome occurs due to interposition of a loop of large intestine in between the liver and the diaphragm. The incidence of Chilaiditi Syndrome is 0.025 to 0.28% and occurs because of congenital anatomical variations of falciform ligament (1). It can also be due to functional abnormalities such as constipation, aerophagia, cirrhosis, paralysis of the diaphragm, chronic lung disease which can cause enlargement of the lower thoracic cavity, obesity, and processes which increase intra-abdominal pressure (1,2). Initial management includes conservative therapy - Bed rest, intravenous fluid hydration, and bowel decompression. Surgical options can be considered (3).

Priyanka Makkar, M.D.¹, Rishabh Mishra, M.D.¹, and Shivanck Upadhyay, M.D.²

¹Internal Medicine department, St. Barnabas Hospital, Bronx, New York

²Department of Pulmonary Critical Care Medicine, St. Barnabas Hospital, Bronx, New York

References

1. Alva S, Shetty-Alva N, Longo WE. Image of the month. Chilaiditi sign or syndrome. Arch Surg. 2008 Jan;143(1):93-4. [CrossRef] [PubMed]
2. Fisher AA, Davis MW. An elderly man with chest pain, shortness of breath, and constipation. Postgrad Med J. 2003 Mar;79(929):180, 183-4. [CrossRef] [PubMed]
3. Blevins WA, Cafasso DE, Fernandez M, Edwards MJ.Minimally invasive colopexy for pediatric Chilaiditi syndrome. J Pediatr Surg. 2011 Mar;46(3):e33-5. [CrossRef] [PubMed]

Cite as: Makkar P, Mishra R, Upadhyay S. Medical image of the week: Chilaiditi syndrome. Southwest J Pulm Crit Care. 2016;13(4):179-80. doi: http://dx.doi.org/10.13175/swjpcc077-16 PDF

Medical Image of the Week: Abdominal Hematoma

 

Figure 1. Contrast-enhanced CT abdomen/pelvis showing A) coronal and B) sagittal views of a LLQ hematoma (blue braces) with active contrast extravasation (red arrow). Lines represent the level of respective axial images. C-F) Axial images demonstrating the hematoma within and expanding the rectus abdominis sheath (blue braces) as well as active contrast leak (red arrow).

Figure 2. A) Arteriogram demonstrating the large hematoma (solid arrow) with active extravasation of contrast from the inferior epigastric artery (arrowhead) arising from the external iliac artery (empty arrow). B) Coils in the inferior epigastric artery (arrow) block flow to the hematoma.

A 59 year-old man presented to clinic with acute-on-chronic non-productive cough along with sore throat and myalgias for 2 weeks and lower left quadrant (LLQ) abdominal pain for 2-3 days. He was a current smoker with history significant for COPD and mild “smoker’s cough” controlled with daily anticholinergic and as-needed beta-agonist, paroxysmal atrial fibrillation on dabigatran and diltiazem, hypertension controlled by diuretic, and a former alcoholic with hemochromatosis.

While getting an x-ray, he had a coughing fit resulting in abrupt worsening of his LLQ pain enough to inhibit ambulation. Due to his inability to walk, he came via ambulance to the emergency department, where he was mildly tachycardic with a 10cm firm, tender and ecchymotic LLQ mass.

Contrast-enhanced abdominal/pelvic CT demonstrated a large rectus abdominis hematoma. Figure 1 shows the hematoma within the rectus sheath measuring 16 cm with active contrast extravasation. The patient went directly to the interventional suite, where the left inferior epigastric artery was catheterized and subsequently embolized as shown in Figure 2.

The patient was noted to be in atrial fibrillation with rapid ventricular response (AFRVR), so was taken to the intensive care unit and placed on diltiazem drip, given digoxin and 1 unit of RBCs before his rhythm stabilized and he was transferred to the floor. His hemoglobin remained stable, and his cough and abdominal pain improved, so he was sent home off anticoagulation until follow-up with his cardiologist.

In the RE-LY trial, updated in 2010 (1), there was no difference in bleeding complications at this patient’s dosing of dabigatran compared to warfarin with INR of 2.0-3.0. However, this patient did not bleed into a critical area, require 2 units of RBCs, nor drop hemoglobin >2mg/dl, and would thus be considered having a minor bleeding event despite needing emergent embolization, losing enough blood to become tachycardic with resulting AFRVR, and getting 1 unit of RBC

Despite this particular bleeding complication, in a meta-analysis examining dabigatran vs warfarin, dabigatran uniformly was as good or better in preventing strokes with less devastating complications than warfarin (2). Additionally, although warfarin is touted as having vitamin K as its reversal agent, protein synthesis and secretion into the vasculature takes hours, similar in time to metabolically clear dabigatran (3).

In the end, after discussions about anticoagulants with the hospital team before discharge and his cardiologist thereafter, the patient elected to restart his dabigatran.

Michael Larson, M.D., Ph.D.

Banner-University Medical Center

University of Arizona

Medical Imaging Department

Tucson, AZ, USA

References

1. Connolly SJ, Ezekowitz MD, Yusuf S, Reilly PA, Wallentin L; Randomized Evaluation of Long-Term Anticoagulation Therapy Investigators. Newly identified events in the RE-LY trial. N Engl J Med. 2010 Nov 4;363(19):1875-6. [CrossRef] [PubMed]
2. Gómez-Outes A, Terleira-Fernández AI, Calvo-Rojas G, Suárez-Gea ML, Vargas-Castrillón E. Dabigatran, rivaroxaban, or apixaban versus warfarin in patients with nonvalvular atrial fibrillation: a systematic review and meta-analysis of subgroups. Thrombosis. 2013;2013:640723. [CrossRef] [PubMed]
3. Ganetsky M, Babu KM, Salhanick SD, Brown RS, Boyer EW. Dabigatran: review of pharmacology and management of bleeding complications of this novel oral anticoagulant. J Med Toxicol. 2011 Dec;7(4):281-7. [CrossRef] [PubMed]

Cite as: Larson M. Medical image of the week: abdominal hematoma. Southwest J Pulm Crit Care. 2016:13(4): 176-8. doi: http://dx.doi.org/10.13175/swjpcc083-16 PDF