Hepatodiaphragmatic interposition of the bowel is
frequently an asymptomatic and rare clinical condition
which remains as an undiagnosed entity during whole life
time. In a period of time when the literature was reviewed,
we have found 110 articles reporting approximately 150
cases of Chilaiditi’s syndrome since 1965. Most of them
associated with various disorders including the colonic
volvulus, supra-hepatic appendicitis, scleroderma, congenital
hypothyroidism, melanosis coli, salmonellosis and
obesity, which seem to be reasonably related or without
clear relationship to the disease. Also there were a few
articles about Chilaiditi’s syndrome associated with mammarian,
colonic, gastric and pulmonary malignancies [
2-
4,
8].
Although frequently an asymptomatic clinical event
Chilaiditi’s syndrome combine with symptoms such as
abdominal pain, nausea, vomiting, distention, flatulence,
substernal pain, incomplete intestinal obstruction, and the
condition consisting with cardiac arrhythmias and even
difficult respiration [7,9]. In plain X-ray of the chest, the
appearance of air collection marking with haustral signs
in the subdiaphragmatic area gives a strong hint to diagnose.
However subdiaphragmatic abscess show characteristics
similar to the hepatodiaphragmatic interposition
of the colon. If doubts still remain after plain X-ray of the
chest CT combined with radio contrast media will be suggested
to make a certain diagnosis [10]. If diagnosed in
first step required treatment is usually a conservative one
with bed-rest and nasogastric decompression. When the
symptoms give a processing course to acute intestinal obstruction,
surgical treatment then can be a requisite [11].
In addition, a few articles about colonic volvulus with
Chilaiditi’s syndrome were found in literature [10,12,13].
One case was about gastric volvulus and the other was
about recurrent colonic volvulus [2,14].
Some intestinal, diaphragmatic and hepatic factors
induce progression of Chilaiditi’s syndrome. Absence of
peritoneal attachments and redundant colon with a long
mesentery, abnormal colonic motility are the intestinal
factors. A possible diaphragmatic factor is the location of
abnormal upright position of diaphragm due to muscular degeneration of phrenic nerve injury. Hepatic factors incorporate
small liver (cirrhosis), relaxation of suspensor
ligaments.
In our four cases of Chilaiditi’s syndrome, we realized
the colonic elongation and indulgent suspensory ligament
of the colon as predisposing factors. But we could not find any relationship between the factors and pancreatic
malignancy. The accompaniment of the pancreatic cancer
with the Chilaiditi’s syndrome in those cases may possibly
be coincidental, but the similar dyspeptic symptoms
of each disease especially in the early stage of pancreatic
cancer may mimic each other.
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