Minimally invasive colopexy for pediatric Chilaiditi syndrome

Symptomatic hepato-diaphragmatic interposition of a bowel loop or Chilaiditi’s syndrome is a peculiar anatomical condition most often found by chance Its described symptoms range from intermittent, mild abdominal pain and dyspepsia to acute intestinal obstruction We report a case of hepato-diaphragmatic migration of the hepatic flexure of the colon associated to an unusual, heretofore unreported, angina-like pain exclusively evoked by the left lateral decubitus To maximize the chance of observing anatomical changes in different postures, computed tomography of the chest and abdomen was performed after air insufflation into the colon While frank herniation into the chest was excluded, the scan showed that the hepatic flexure-with the interposition of the diaphragm-came in contact with the right side of the heart in the left lateral, but not in the supine, decubitus This finding was reproduced by echocardiography which also showed virtually unaltered hemodynamics after the change of posture ECG, left and right ventricular global and regional function as well as cardiac injury markers also remained unchanged during the maneuver, indicating that the pain evoked by the latter was unlikely due to myocardial ischemia This case suggests that Chilaiditi’s syndrome should be included among the possible, although rare, causes of unexplained angina-like symptoms

Heart-touching Chilaiditi's syndrome.

Hernia through the falciform ligament accounts for 0.2% of internal hernias. A congenital etiology for these defects is probable. Contributing risk factors include visceral displacement into the upper abdomen and excessive visceral mobility. Patients present most commonly with symptoms of bowel obstruction. Chilaiditi Syndrome on abdominal roentgenograms and abdominal computed tomography may aid in diagnosis. Treatment consists of eliminating the hernia defect by suture ligation and division of the falciform and ligamentum teres as well as surgical management of secondary bowel ischemia if present. The existence of ‘parafalciform hernia’ and ‘bowel stringing falciform obstruction’ must also be recognized as possible etiologies for visceral obstruction or strangulation caused by the falciform ligament.

Internal herniation through a defect in the falciform ligament: a case report and review of the world literature

Chilaiditi syndrome, first described in 1910 by Viennese radiologist Chilaiditi, is the interposition of the right colon between the liver and the right hemi diaphragm. 1 The syndrome is generally asymptomatic, however, abdominal pain, distension, anorexia, constipation and respiratory distress may occur. Occasionally, it has been associated with a number of severe complications such as internal hernias, colonic volvulus and acute intestinal obstruction. 2,3 Chilaiditi syndrome is an extremely rare disease of childhood as only few cases have been reported so far. 3–6 The present study reports a case of a 4-year-old-boy with respiratory distress and abdominal pain episodes, diagnosed with Chilaiditi syndrome.

Unusual cause of respiratory distress: Chilaiditi syndrome.

Chilaiditi’s syndrome refers to the symptoms of abdominal pain, distention, vomiting, anorexia, and constipation caused by hepatodiaphragmatic interposition of the intestine. Although patients with this radiographic finding are commonly asymptomatic, presentation with symptoms is rare and accurately refers to this syndrome. There is an increased incidence of Chilaiditi’s syndrome among mentally ill adults. Traditionally, Chilaiditi’s syndrome is managed medically by discontinuing causative medicines. However, among the mentally ill population whose psychotropic medications precipitate the interposition of the colon, ceasing these psychotropic medications is not an appropriate option. The case presented involves a mentally ill patient with Chilaiditi’s syndrome who was successfully managed with laparoscopic colopexy. At follow-up, the patient reported marked improvement of abdominal symptoms.

Laparoscopic management of Chilaiditi's syndrome.

PreviewChilaiditi's syndrome is a relatively common radiologic finding that may be confused with free air under the diaphragm or other chest or abdominal disorders requiring surgical intervention. Drs Haddad and Lacle describe a case in which a chest radiograph was initially misinterpreted before the correct diagnosis of Chilaiditi's syndrome was made.

Chilaiditi's syndrome. A diagnostic challenge.

P157 Figure 1DiscussionOf those who attended, the LTBI rate was 20%, highlighting the importance of targeted population screening. Early identification prevents some cases developing active TB. 7 active TB cases were identified early, with improved patient outcomes and reduced contacts. Limitations are the poor uptake, partly due the COVID-19 pandemic (service suspension). Barriers include language (non-English speakers);lack of understanding about latent TB;stigma associated with TB;financial constraints;and temporary accommodation of this population, hence difficulty arranging appointments. Leaflets in different languages and work with community and religious leaders would help to raise awareness.ReferencesTuberculosis in England 2021 report – UK Health Security Agencyhttps://www.england.nhs.uk/tuberculosis-programme/area-for-action-8-national-latent-tb-infection-testing-and-treatment-programme/

Judella Haddad Lacle

Papers

Chilaiditi's syndrome. A diagnostic challenge.

P157 A nurse-led new entrant latent TB infection screening clinic- the Croydon experience