Presentation
Abdominal pain.
Patient Data
The terminal ileum, cecum, ascending colon, and hepatic flexure are interposed between the anterior right hepatic lobe and undersurface of the right hemidiaphragm. This segment of colon has thickened, edematous walls and mucosal hyperenhancement. On the coronal images, there may be some degree of tension/compression on the ileocolic vessels contributing to this congested appearance. The remainder of the transverse and descending colon is normal.
There is also focal wall thickening and subtle inflammation involving a short segment of the sigmoid colon. There is diverticulosis, but no definite inflamed diverticulum is identified. While nonspecific, I favor subacute or low-grade diverticulitis.
3-months later ischemia/inflammation resolved
This is a 3-month follow-up to the first study where the patient has findings of Chilaiditi syndrome. There is persistent interpositioning of the right colon between the liver and right hemidiaphragm, however, the abnormal thickening and inflammation/ischemia of the right colon has resolved. There are no acute findings.
CT obtained 2-yrs prior to the initial presentation redundant Rt colon without interposition.
For the sake of completeness, a study that was performed 2-years prior to the patients presentation is also included. The right colon is redundant and filled with stool. However, it is not interposed between the liver or right hemidiaphragm at this time. There are no findings of active inflammation of infection.
Case Discussion
The patient has characteristic findings of Chilaiditi syndrome: interposition of the colon between the right hepatic lobe and right hemidiaphragm, abnormal appearance suggesting congestion/ischemia or inflammation, and abdominal pain. The patient received supportive care and did not require operative intervention. On subsequent CT examinations, the patient had similar positioning of the colon, but resolution of the abnormal appearance.
As is often the case in radiology, one abnormality isn't the end of the picture: there is also subtle inflammation of the sigmoid colon, which could represent subacute or low grade diverticulitis. It would be reasonable to conjecture that this contributed to transient ischemia of the right colon in this study. Some degree of tension/compression of the ileocolic vasculature due abnormal colonic position might put this location at risk, and low-flow related ischemia is frequently a cause of ischemic colitis in older patients (which could result from inflammation/infection in the sigmoid colon causing transient hypotension). The sigmoid colon inflammation also resolved on future exams.
Two other studies have been included for completeness, as imaging findings supporting Chilaiditi syndrome are very rare and difficult to come by. The additional cases shed some light on the pathogenesis and natural history: The earliest study was obtained 2-years prior the patient's presentation, and shows redundant right colon which is filled with stool, but not interposed between the liver and hemidiaphragm. Thus, colonic redundancy likely contributed to the colon migrating cranially on future studies. The second study is a 3-month follow-up exam obtained after the acute presentation. This shows resolution of the colonic inflammation/ischemia. It would be possible that over time, the patient developed compensatory blood flow to the originally at-risk/ischemic colon, and thus the imaging abnormalities resolved.
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