Management of Colonic Interposition Below Right Hemidiaphragm (Chilaiditi Syndrome)
Conservative management is the first-line approach for colonic interposition below the right hemidiaphragm (Chilaiditi sign/syndrome), with surgical intervention reserved only for cases with complications such as bowel obstruction, ischemia, or perforation. 1, 2
Diagnostic Criteria
- Radiological findings must meet three criteria:
- Right hemidiaphragm elevated above liver by intestine
- Bowel distended by air (pseudo-pneumoperitoneum appearance)
- Superior margin of liver depressed below level of left hemidiaphragm 1
- Important distinction: Chilaiditi sign (asymptomatic radiological finding) vs. Chilaiditi syndrome (symptomatic presentation)
Management Algorithm
Step 1: Assess for Complications/Emergencies
- Evaluate for signs of peritonitis, bowel obstruction, or perforation
- Check vital signs for hemodynamic instability
- If patient shows signs of shock, peritonitis, or perforation, proceed directly to surgical management 3
Step 2: Conservative Management (First-Line)
For uncomplicated cases:
- Bowel rest (NPO status)
- Aggressive intravenous fluid resuscitation
- Correction of electrolyte abnormalities
- Nasogastric decompression if significant distention
- Bowel regimen to treat constipation (common underlying factor)
- Positioning therapy (supine or right lateral decubitus position)
- Monitor colon diameter as indicator for potential complications 4
Step 3: Monitoring Response
- Serial abdominal examinations
- Follow-up imaging to assess colon diameter and position
- Monitor for development of complications
- If symptoms persist >48-72 hours despite conservative measures, consider surgical evaluation
Step 4: Surgical Management (Reserved for Specific Indications)
Indications for surgery:
- Failed conservative management
- Signs of bowel obstruction or ischemia
- Recurrent symptomatic episodes
- Perforation
Surgical approaches:
- Laparoscopic approach preferred for stable patients 3
- Open laparotomy for unstable patients or complex cases 3
- Procedures may include:
- Colon mobilization and repositioning
- Colopexy
- Segmental resection if bowel compromise present
Special Considerations
Distinguishing from True Pneumoperitoneum
- Critical to differentiate Chilaiditi sign (pseudo-pneumoperitoneum) from true pneumoperitoneum
- CT imaging is more definitive than plain radiographs
- Haustral markings visible in Chilaiditi sign but absent in true pneumoperitoneum
Risk of Perforation
- Monitor colon diameter as direct predictor of perforation risk
- Dilation >6 cm indicates high risk for perforation 4
- Progressive colonic dilation correlates with increased perforation risk
Post-Surgical Care
- If surgical intervention was required, standard post-colonic surgery care applies
- Early enteral nutrition when feasible
- Avoid routine nasogastric tubes post-operatively unless specifically indicated 3
- Consider thromboembolism prophylaxis with LMWH and compression stockings 3
Common Pitfalls to Avoid
- Misdiagnosing as pneumoperitoneum leading to unnecessary surgical intervention
- Performing high-risk colonoscopy in patients with Chilaiditi sign
- Delaying surgical consultation when conservative management fails
- Overlooking underlying causes (chronic constipation, anatomic variations)
- Attempting primary anastomosis in unstable patients if resection is needed 3
Most cases of Chilaiditi syndrome can be successfully managed with conservative measures. Surgical intervention should be reserved for cases with complications or failure of conservative management.