Chilaiditi syndrome in a peritoneal dialysis patient

A 55-year-old woman with end-stage renal disease from IgA nephropathy started continuous ambulatory peritoneal dialysis (CAPD). Three months later, she was admitted with sudden onset of right flank pain. She had undergone total hysterectomy 2 years ago and PD catheter placement 8 months ago. On admission she was afebrile and abdominal examination showed no sign of peritoneal irritation. Chest X-ray revealed air under the right diaphragm with haustrations suggestive of colonic air (Figure 1). CAPD fluid and blood test detected no sign of peritonitis. Abdominal computed tomographic (CT) scan revealed interposed colon between the liver and the diaphragm (Figure 2). Analgesics did not relieve her pain. Given a possibility of volvulus, laparoscopic enteropexy was planned. However, the pain was abruptly relieved after drainage of CAPD fluid and the subsequent chest X-ray showed that the interposed colon was no longer present. She has not experienced relapse since the last 6 months. Chilaiditi sign is asymptomatic appearance of interposed bowl between the liver and the diaphragm. It is found with an incidence of 0.025–0.28% in X-ray and of 1.2–2.4% in abdominal CT. With the presence of clinical symptoms, the condition is referred to as ‘Chilaiditi syndrome’. This condition is usually treated conservatively but rarely surgery is indicated in case of ileus, perforation, and ischemia. The predisposing factors include ascites, pregnancy, and any other conditions leading to an enlarged space under the right diaphragm or hypermobility of intestines.