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Diagnostic imaging
Published in Professor Sir Norman Williams, Professor P. Ronan O’Connell, Professor Andrew W. McCaskie, Bailey & Love's Short Practice of Surgery, 2018
Professor Sir Norman Williams, Professor P. Ronan O’Connell, Professor Andrew W. McCaskie
The erect chest x-ray (CXR) is the ideal first test for hollow organ perforation and as little as 10-20 mL of free air can be detected under the diaphragm, with the following caveats (Figures14.37and14.38): about 10 minutes should be left between sitting the patient upright to allow air time to rise; the free air must be sought under the right hemidiaphragm to prevent misinterpretation of the gastric air bubble; and the reviewer must be able to recognise Chilaiditi’s syndrome, the harmless and asymptomatic interposition of large bowel between the liver and diaphragm. Caution must also be exercised in interpreting any free air in the context of recent abdominal surgery, as air can persist for up to 5-7 days in the peritoneal cavity.
Objective structured clinical examination (OSCE)
Published in Tristan Barrett, Nadeem Shaida, Ashley Shaw, Adrian K. Dixon, Radiology for Undergraduate Finals and Foundation Years, 2018
Tristan Barrett, Nadeem Shaida, Ashley Shaw, Adrian K. Dixon
There is air seen under both hemidiaphragms. This is likely to be secondary to a perforated viscus; ‘pseudo’ pneumoperitoneum can be seen if bowel is interposed between the right hemidiaphragm and the dome of the liver (Chilaiditi syndrome), or if a band of linear atelectasis is seen just superior to the diaphragm.An abdominal X-ray can show free air; the signs are often subtle on a supine film, but this may be useful in showing an underlying cause. The supine film below in the same patient shows a slither of free air in the RUQ, under the liver. An example of a left lateral decubitus AXR (left-side down) in a different patient clearly shows free air above the liver. An abdominal CT can confirm the diagnosis (this study is performed supine, thus free air rises centrally rather than to the hemidiaphragms), this may help to localise the region of perforation pre-operatively. Causes include perforation of an abdominal viscus (e.g. secondary to a duodenal ulcer, a gastric ulcer, or a colonic diverticulum), penetrating abdominal trauma, post surgical (laparotomy / lapaoscopy), inflammatory / infective (e.g. appendicitis, cholecystitis, toxic megacolon), or peritoneal dialysis. In this young patient the perforation was secondary to appendicitis.
Practice Paper 5: Answers
Published in Anthony B. Starr, Hiruni Jayasena, David Capewell, Saran Shantikumar, Get ahead! Medicine, 2016
Anthony B. Starr, Hiruni Jayasena, David Capewell
The presence of free air under the diaphragm (pneumoperitoneum) on chest X-ray indicates a perforated abdominal viscus that has allowed air to enter the peritoneal cavity, e.g. a perforated peptic ulcer. To maximize the chance of seeing free air under the diaphragm, the chest X-ray should be taken with the patient in an erect position. A similar finding may be seen when the transverse colon is interpositioned between the superior border of the liver and diaphragm. This is known as Chilaiditi’s syndrome, or hepatodiaphragmatic interposition of the colon, and is usually an incidental finding in an asymptomatic patient.
Air under the diaphragm—perforation or Chilaiditi sign?
Published in Baylor University Medical Center Proceedings, 2022
Shobha Mandal, Sneha Singh, Barun Kumar Ray, Rahul Kumar Thakur, Anish Kumar Shah, Victor Kolade
The clinical presentation of Chilaiditi syndrome varies significantly. The most common manifestations are postprandial abdominal pain, vomiting, anorexia, and constipation. In some cases, it can also cause shortness of breath and intestinal obstruction.3,5,7 It can lead to complications like volvulus of the cecum, splenic flexure, and transverse colon.8–10 Physical examination ranges from a soft abdomen to abdominal distention with an absence of liver dullness.7 The differential diagnoses of Chilaiditi syndrome include bowel obstruction, volvulus, intussusception, ischemic bowel, and perforation of the intestine and inflammatory conditions.
Chilaiditi syndrome—a clinical conundrum!
Published in Southern African Journal of Anaesthesia and Analgesia, 2018
Supriya Dsouza, Yuvraj Mhaske, Adarsh Kulkarni, Ajit Baviskar
Demetrius Chilaiditi first described hepatodiaphragmatic interposition of hollow viscera in 1910 as an incidental finding on chest X-rays; this is since known as Chilaiditi’s sign.1 It has an incidence of 0.3% on chest X-rays and 2.4% on chest/abdominal CT scans.2 Accompanied by clinical symptoms such as abdominal pain, vomiting, and/or constipation, it is referred to as Chilaiditi syndrome.