Overview

The idea of a loop of bowel getting stuck between your liver and your diaphragm may sound strange at first, but this is a rare condition called Hepatodiaphragmatic Interposition (HI). It is helpful to understand what makes one person more likely to develop it than another person.

HI is a condition where a part of the intestine gets between the liver and the diaphragm.¹ ‘Hepato-’ refers to the liver, while ‘diaphragmatic’ refers to the diaphragm. The diaphragm is the organ underneath the lungs that helps to expand the chest during breathing. Less than 1% of people develop HI worldwide from the ages of 5 months to 81 years.¹ In many cases, it is discovered by chance during scans (Chilaiditi sign) and causes no symptoms.²

Risk factors for hepatodiaphragmatic interposition

Normally, ligaments hold the liver and colon in place. You can think of the colon like a long rope in a confined space, secured by several straps. If the straps are too loose or the rope is longer than usual, it can move around more easily and is more likely to slip between other organs in the space. People can be at risk of developing HI from conditions that they are born with or because of things that happen to them later in life.

Congenital risk factors

Congenital risk factors are those that are present from birth. The intestines are normally held in place by ligaments, connective tissue, and the surrounding organs.³ Some people are born with differences in the composition of their abdomen that make it easier for the intestines to slip between the liver and the diaphragm. 

If the tissues of the diaphragm are weak, the diaphragm is unusually shaped, or it sits higher than usual, there is a higher risk of HI.³ Having a smaller liver or one that is not fully developed is another risk factor.³ The problem can also be with the ligaments that anchor the liver if they are looser, longer, or even absent.³ The composition of the intestines can also be an issue. For instance, having a colon that is very mobile or longer than average increases the risk of it moving into the space between the liver and the diaphragm.¹ Also, during development in the womb, the colon normally rotates many times until it reaches its final position. If this does not occur completely, it can lead to intestinal malposition. This means the intestine is in an incorrect position, and this increases the risk of HI.³ There is little difference in the risk of HI between those assigned male at birth and those assigned female at birth.¹

People with mental illnesses like intellectual disabilities and schizophrenia are also more likely to have HI, as these conditions also affect the growth and structure of some organs.³

Acquired risk factors

Acquired risk factors are those that develop later in life. For HI, these are usually caused by changes in the body related to ageing and other chronic medical conditions.

As a person gets older, the tissues of their diaphragm can get weaker, making it more likely to allow the intestines to slide through. If the liver becomes smaller or there is more pressure in the abdomen, this can also allow the intestines to be moved around more easily and be pushed between the liver and the diaphragm. Cirrhosis is a liver disease where there has been a lot of damage to the liver and it has been scarred, which makes the liver shrink. This makes the gap between the liver and the diaphragm bigger, so the intestines can slip through more easily.¹ Digestive issues such as chronic constipation, excessive bowel gas, tumours, and fluid buildup in the abdomen (ascites) can increase pressure in the abdomen.⁴ Rapid weight gain and weight loss can also change the pressure in the abdomen.¹ Moreover, people who have had surgery or trauma to the abdomen are also at higher risk, as these can change the structure of internal organs and supporting ligaments.⁴ Chronic lung disease can cause the diaphragm to move higher up, and disorders of the nerves and muscles can weaken the muscle of the diaphragm.² These conditions increase the chance of the intestines slipping into this space.

Interactions between congenital and acquired factors

Sometimes, a person may have a congenital condition, but they do not have any symptoms until they get an acquired risk factor later in life. But why does this matter for how HI is managed, and how should doctors respond when risk factors overlap?

Why it matters

It is important for doctors and affected people to be aware of the risk factors of HI, as it helps them to make a diagnosis. Many other conditions can have similar signs and symptoms to HI. Some other conditions that can appear similarly are pneumoperitoneum (air in the area around the stomach), bowel perforation, bowel obstruction, and several others.^2,4 In most cases, HI can be fixed without surgery. But other problems, like pneumoperitoneum, must be fixed with surgery immediately. So, knowing the right problem is important to prevent procedures that are not needed. Some people who are at increased risk of HI can have mild but recurrent symptoms that can be treated with painkillers and medicines that prevent vomiting. 

If people know the risk factors for HI, it can help them make choices to change their lifestyle to prevent Chilaiditi Syndrome, especially if they already have a congenital risk factor. Smoking and drinking lots of alcohol are examples of activities that can really increase a person’s chances of getting lung and liver diseases. These health issues can boost the risk of Chilaiditi Syndrome and, if someone already has it, make the symptoms worse. Even though Chilaiditi Syndrome is usually easy to treat and most people have mild symptoms, leaving it untreated can lead to serious complications. Some life-threatening complications of Chilaiditi Syndrome include volvulus (where a part of the intestine twists upon itself), caecal perforation (a tear in the wall of the first part of the colon), and mesenteric ischaemia (blockage of blood flow to the intestines).^2,5 These need to be treated in the hospital immediately.  

FAQs

What can I do to prevent chilaiditi syndrome?

You can prevent Chilaiditi Syndrome by preventing the development of acquired risk factors. It is good to maintain a healthy weight, and you should avoid gaining or losing a lot of weight too quickly to lower your risk of Chilaiditi Syndrome. You can do this by following healthy eating and exercise habits. You can avoid lung disease, liver disease and cancer by not smoking, drinking alcohol and eating processed foods too much. It is also important to eat enough food with fibre to prevent constipation and excessive straining, which can make the pressure in the abdomen higher.

Can having multiple risk factors make chilaiditi syndrome worse?

Yes. A person might have a congenital condition that causes HI, but they will have few or no symptoms until they also develop an acquired factor that worsens the symptoms of Chilaiditi Syndrome. For example, in someone born with a colon that can move around a lot, the colon may get between the liver and the diaphragm more easily and more often, but they might not have any symptoms or just have mild symptoms. However, if they later develop an acquired factor, like chronic constipation, this can increase the pressure in the abdomen, making it more likely for the colon to get trapped in this space.

How do I know if I have hepatodiaphragmatic interposition?

Most people do not know they have HI until Chilaiditi’s Sign is found accidentally on a medical scan, usually an X-ray of the abdomen. Others may experience symptoms; commonly, they may have abdominal pain, bloating, constipation, nausea, or shortness of breath. Severe symptoms like sudden, intense abdominal pain, vomiting, or an inability to pass stool may be the result of a complication of Chilaiditi Syndrome. If you have any of these, you should seek medical attention immediately.

Summary

HI is a rare condition in which a loop of intestine gets between the liver and the diaphragm. It is often discovered incidentally during medical scans, and it usually causes no symptoms. There are congenital and acquired risk factors for HI.

Congenital risk factors include:

• A small or unusually shaped liver
• A weak or abnormally shaped diaphragm
• Lax or absent ligaments anchoring the liver
• A very mobile or long colon
• Intestinal malrotation
• Mental illnesses

Acquired risk factors include:

• Age-related weakening of the diaphragm
• Liver shrinkage or cirrhosis
• Chronic constipation, excess gas, tumours, or fluid in the abdomen
• Rapid weight changes
• Prior surgery or abdominal trauma
• Chronic lung disease or nerve/muscle disorders affecting the diaphragm

Congenital factors may remain silent until combined with acquired factors. Most cases can be managed without surgery. Getting a correct diagnosis is important to avoid unnecessary procedures. Making healthy lifestyle choices and maintaining lung and liver health can reduce the chance of developing acquired risk factors of HI.