Incidental detection of Chilaiditi sign in an asymptomatic 28-year-old woman during routine pre-travel screening

Abstract

Chilaiditi sign is an uncommon radiographic finding characterized by interposition of the bowel between the liver and diaphragm and is often identified incidentally in asymptomatic individuals. Its clinical significance lies in its potential to mimic serious intra-abdominal conditions, leading to unnecessary diagnostic or surgical interventions if misinterpreted. We report the case of a 28-year-old woman undergoing routine pre-travel screening in whom Chilaiditi sign was incidentally detected on posteroanterior chest radiography. The patient was asymptomatic, with unremarkable physical examination and normal laboratory findings. Imaging demonstrated a gas-filled colonic loop with visible haustral markings beneath the right hemidiaphragm, without evidence of free intraperitoneal air. Given the absence of symptoms and the presence of characteristic imaging features, no further investigations or interventions were required. This case highlights the importance of recognizing this benign entity and correlating radiologic findings with clinical presentation to avoid unnecessary procedures.

Introduction

Chilaiditi sign is a radiographic finding characterized by the interposition of a segment of the colon or, less commonly, the small intestine between the liver and the diaphragm [1,2]. The reported worldwide incidence of Chilaiditi sign on plain chest and abdominal radiographs ranges from 0.25% to 0.28%, and it demonstrates a clear male predominance with a male-to-female ratio of approximately 4:1 [[2], [3], [4]].

When this radiologic finding becomes associated with gastrointestinal symptoms, it is referred to as Chilaiditi syndrome [1,2]. Clinical manifestations can vary widely, ranging from mild abdominal complaints such as abdominal pain, anorexia, nausea, vomiting, flatulence, constipation, and alterations in bowel habits to respiratory distress and, in severe cases, features of an acute abdomen [2,[4], [5], [6], [7]]. Although the exact rate of complications has not been clearly established, reported complications of Chilaiditi syndrome include volvulus involving the cecum, splenic flexure, or transverse colon, as well as cecal perforation and, rarely, perforated subdiaphragmatic appendicitis [7,8].

We report a case of an asymptomatic 28-year-old woman in whom Chilaiditi sign was incidentally detected during routine pre-travel screening. This case highlights the importance of correlating imaging findings with clinical assessment to prevent unwarranted interventions.

Case presentation

A 28-year-old woman presented to our health screening unit for a routine medical evaluation as part of pre-travel clearance under the Wafid program (for individuals seeking employment or residency in any of the Gulf Cooperation Council states). She was asymptomatic at presentation and reported no active medical complaints. Her past medical history was unremarkable, with no history of chronic illness, prior abdominal surgery, gastrointestinal symptoms, or respiratory disease. She denied abdominal pain, nausea, vomiting, constipation, dyspnea, chest pain, or recent weight loss. She had no history of smoking or alcohol intake and was not taking any regular medications. She had no known allergies.

On physical examination, the patient appeared well and in no acute distress. Her vital signs were within normal limits, including a blood pressure of 118/72 mmHg, heart rate of 74 beats per minute, respiratory rate of 16 breaths per minute, temperature of 36.7°C, and oxygen saturation of 98% on room air. General physical examination was unremarkable. Abdominal examination revealed a soft, nontender abdomen with no distension, guarding, or rebound tenderness. Bowel sounds were normal, and no organomegaly or palpable masses were detected.

As part of routine pre-travel tuberculosis screening, a posteroanterior chest radiograph was obtained. The radiograph demonstrated interposition of a gas-filled colonic loop between the liver and the right hemidiaphragm, with visible haustral markings within the gas shadow, consistent with Chilaiditi sign. The lung fields were clear, and the cardiac silhouette was normal in size and contour. No evidence of free intraperitoneal air suggestive of pneumoperitoneum was observed Fig. 1. Given the classic radiographic features and the patient’s absence of symptoms, further imaging, such as abdominal CT, was not considered necessary.

Fig. 1.

Chilaiditi sign on chest radiograph Posteroanterior chest radiograph showing a gas-filled colonic loop interposed between the liver and right hemidiaphragm with visible haustral markings (black arrow).

Laboratory investigations, including complete blood count, liver function tests, renal function tests, and serum electrolytes, were all within normal reference ranges. The patient was reassured regarding the benign nature of this incidental finding, and no further diagnostic evaluation or specific treatment was required.

Discussion

Although the exact etiology remains unclear, the development of Chilaiditi sign and syndrome is thought to involve a combination of intestinal, hepatic, and diaphragmatic factors. Under normal circumstances, suspensory ligaments and colonic attachments maintain the colon in its anatomical position and prevent its interposition between the liver and the diaphragm. However, anatomical variations such as laxity or absence of these ligaments, elongation of the colon, or congenital malposition may predispose individuals to this condition. In addition, several functional and acquired factors, including chronic constipation, aerophagia, hepatic atrophy, diaphragmatic paralysis, chronic pulmonary disease, obesity, multiple pregnancies, and ascites, can further increase the likelihood of colonic interposition [5,7].

Although most cases are asymptomatic and are detected incidentally on imaging studies such as X-ray or CT scan, Chilaiditi sign can occasionally be misinterpreted as more serious conditions, including pneumoperitoneum, diaphragmatic hernia, bowel obstruction, bowel perforation, or other causes of acute abdomen. Such misdiagnoses may lead to unnecessary investigations and even unwarranted surgical interventions [3,5,8,9]. In our patient, the absence of clinical symptoms combined with clear visualization of haustral markings on the PA chest radiograph allowed us to confidently avoid further diagnostic procedures.

The presence of Chilaiditi sign alone typically does not require any specific treatment [4]. However, management of patients with mild symptoms of Chilaiditi syndrome is generally conservative. Recommended measures include bed rest, intravenous fluid therapy, nasogastric decompression, enemas, a high-fiber diet, stool softeners, and increased dietary fiber intake to decrease colonic distention and enhance bowel motility, particularly in patients with constipation [[3], [4], [5]]. If symptoms persist despite conservative management, surgical intervention may be considered. Surgical options include procedures such as colopexy, hepatopexy, or bowel resection [3,9,10].

Conclusion

Chilaiditi sign is a rare radiographic finding that is usually asymptomatic and often discovered incidentally. Recognition of this condition is crucial, as it can mimic more serious intra-abdominal pathology and may lead to unnecessary investigations or interventions. In asymptomatic patients, like the one presented here, conservative management and reassurance are sufficient. Awareness of this entity allows clinicians to provide appropriate care while avoiding unwarranted diagnostic or surgical procedures.

Patient consent

Written informed consent has been obtained from the patient for publication of the case report and any accompanying images. A copy of the written consent is available for review upon request by the Editor-In-Chief of this journal.