Introduction

If you were to visit the doctor, and after describing your symptoms, the doctor recommending a diagnostic exam, and the eventual diagnostic result showing an abnormal region, a displacement of your bowel between your liver and your diaphragm (a dome-shaped muscle at the bottom of your lungs,¹ connected to your lower ribs),² the doctor may diagnose your condition as Chilaiditi’s syndrome. 

Chiladiti’s syndrome is frequently misdiagnosed as more serious conditions, which can result in unnecessary treatments. However, physicians can use computer tomography (CT) imaging to enhance diagnostic accuracy.  This helps doctors better determine what’s present between the liver and diaphragm - whether it’s bowel or air - allowing them to avoid unnecessary procedures and ensure the right care for the patient.

Understanding chilaiditi’s syndrome

Sign versus syndrome

For medical clarity, there are two related but distinct terms - Chilaiditi’s sign and Chilaiditi’s syndrome. Chilaiditi’s sign relates to the identified region between the liver and diaphragm,⁴ with no associated symptoms.⁵ However, Chilaiditi’s syndrome involves both the abnormal region as well as the symptoms.⁵ These distinctions can help you, as a patient, better understand the severity and nature of the condition you’re facing.

Diagnosis of chilaiditi’s sign

When doctors can  properly diagnose Chilaiditi’s sign from radiological results, the following conditions will be observed:

• The elevation of the right side of the diaphragm, above the liver⁵
• The identified presence of the intestine between the diaphragm and the liver⁵
• The part of the liver that is superior, i.e., nearest to the head of the body, is placed below the diaphragm’s left side⁵
• The bowel -  comprising the small intestine, large intestine, and colon-, may appear filled with air, and not otherwise⁵
• The absence of free air in the abdominal area, i.e., outside of the bowels and organs⁵

Symptoms of chilaiditi’s syndrome

 The symptoms of Chilaiditi’s syndrome can be similar to those of other conditions and may include the following:

• Abdominal pain 
• Nausea 
• Bloating
• Constipation 

 Therefore, Chilaiditi’s syndrome is important to recognise in a clinical setting, as there is a risk of misdiagnosis.

Misdiagnoses

 If a doctor misinterprets the diagnostic results, they may mistakenly diagnose the patient with one of the following conditions, which are more serious than Chilaiditi’s syndrome:

• Hernia - The abnormal protrusion of abdominal tissue or organ through the abdominal wall,  such as when the intestine pushes through a tear in the belly button area⁶
• Perforation- A tear in the lining of an organ or vessel, such as a bowel or intestine perforation, that allows its contents to leak into the abnormal cavity⁷
• Pneumoperitoneum - The presence of air within the cavity of the abdomen, mostly caused by a perforation;⁸ with this condition, air is also shown in a typical X-ray, in a similar way to that of Chilaiditi's syndrome⁹
• Subphrenic abscess - A condition identified by the unusual presence or excess amount of fluid below the diaphragm¹⁰

Unfortunately, due to these misdiagnoses, the doctor may prescribe unnecessary interventions that can worsen the already affected region, causing more harm and less benefit. A hernia is treated with surgery. For pneumoperitoneum, the treatment is a laparotomy, used to correct abdominal free air. Regarding a subphrenic abscess, a catheter drainage is used to remove the excess fluid in the abdomen. One can only imagine how detrimental it would be to find a lack of these three conditions during treatment, with a high risk of damaging a previously intact but out-of-place intestine (or bowel).

Diagnostic methods

In medical practice, multiple methods may be used to diagnose Chilaiditi's syndrome, though each has its limitations.

Conventional radiography

Conventional radiography, or X-ray, creates two-dimensional images of a part of the human body.¹¹ This is done by passing controlled radioactive rays through the body onto a detector. X-rays will pass through the lighter, fleshy areas that lack bone, but will be blocked by denser bone tissue. Thereby, typical X-ray images visualise the bones in a lighter shade than the surrounding areas. Conventional radiography can show the abnormal space between the liver and the diaphragm, but due to the lack of detail in a 2D image X-ray, this space could be easily mistaken for free air (possibly linked to a perforation).¹² Therefore, conventional radiography assists in diagnosing abnormalities in the abdominal area, albeit with much room for error and uncertainty.¹³

Ultrasound

An ultrasound uses a scanner to emit high-frequency sound waves. These waves travel through the abdomen, including the flesh, fluid, and bone, and are reflected back. The echoes are then converted into electrical signals to create an image of the tiddue boundaries. A gel is used to limit any air pockets that exist between the emitting side of the scanner and the skin. While it is a more effective diagnostic tool in this instance, it is still limited by the presence of bowel gas and may be inconclusive in meeting the diagnostic checkmarks for Chilaiditi's sign/syndrome.¹⁴ Therefore, it can be paired with an abdominal CT scan for further clarification of the diagnosis.¹⁵,¹⁶

Computed tomography (CT) 

A CT scanner directs a narrow beam of X-rays at the body while rapidly rotating around the person.¹⁷ Signals are thereby produced, which the CT computer processes to form clear 2D, cross-sectional images. These are then put together to form a 3D image of the person, their internal structures, as well as any possible abnormalities.¹⁷ In the case of the bowel, a barium-based contrast agent (administered through the mouth) is used to easily visualise the soft tissues by restricting the passage of X-rays.¹⁷ With these added areas of clarity in the diagnostic process, CT imaging can accurately show the loop of the intestine between the diaphragm and the liver, and thereby assist in correctly diagnosing Chilaiditi's sign/syndrome (from pneumoperitoneum or other conditions) and in identifying the associated complications such as the twisting of the bowel/intestines.¹⁸

CT findings in chilaiditi’s syndrome

The following are the observations a doctor can make through the findings of a CT scan:

• A clear view of the intestine/bowel being positioned between the liver and the diaphragm
• No presence of free air or settled fluid
• Evidence of restricted blood supply with the help of contrast-enhanced CT

Clinical impact of CT imaging

It is important to make an accurate diagnosis of Chitaiditi’s sign or syndrome. With proper imaging, such as a CT scan, unnecessary procedures such as open surgery (laparotomy) - along with their associated risks, costs, and complications - can often be avoided. Doctors can thereby guide the treatment of non-emergency patients, including bed rest, bowel rest, and IV (intravenous) fluids.⁵ Moreover, case studies support how misdiagnoses can be avoided or resolved; e.g. 1) a 65-year-old male diagnosed with an inflamed inner-abdominal wall (peritonitis), was later diagnosed with Chilaiditi's syndrome and treated nonoperatively,¹⁹ while 2) a 61-year-old female said to have pneumoperitoneum, after a chest X-ray, was eventually tested with a CT scan and diagnosed with Chiaiditi's syndrome; she improved significantly after the use of IV treatment.²⁰ Additionally, in the more severe cases where the bowel/intestines cannot be non-surgically normalised, CT scans can aid in a careful surgical intervention.⁵ The overall clinical impact of CT imaging is positive, ensuring that the results are as precise and accurate as possible, leading to a more certain diagnosis.

Considerations and risks

• According to a 5-year study, the average cost of a CT scan for two hundred and eighty (280) patients was $4510 USD.²¹ This cost, amid varying economic factors, can be very expensive, especially for low-income individuals
• There is a risk of damage due to the patient's exposure to radiation, but the chance is small due to the controlled emittance of the radioactive beams, which help to accurately diagnose a patient's condition
• CT imaging must be correlated with a proper assessment of the patient’s symptoms and history

Future directions 

• Artificial intelligence (AI) will improve image accuracy, automate some of the significant tasks, and assist in better pattern recognition²²
• Awareness is encouraged through continuously educating clinicians and radiologists, so that the rate of misdiagnosis can be significantly lowered

FAQs

Why is this syndrome named ‘Chilaiditi’s’?

Chilaiditi’s syndrome is named after Demetrius Chilaiditi, a Greek radiologist who discovered incidental findings for three patients in 1910. He was the first to describe the features of the colon being interposed between the liver and the diaphragm, through a radiograph.⁴

Is CT Imaging/Scan the same as a CAT Scan?

Yes, Computed Tomography (CT) scan was originally called a Computed Axial Tomography (CAT) scan, and both refer to a procedure in which a combination of X-rays and computer technology are used to show detailed images of the body’s structures. Helping doctors make a diagnosis.⁴

Summary

Chilaiditi's syndrome is an uncommon but important condition that requires a conclusive diagnosis. CT imaging can be extremely helpful in confirming it. CT is beneficial in giving physicians a clearer view of a patient's abdominal state, helping them avoid unnecessary interventions, whilst improving safety, and optimising patient care. By enhancing the diagnostic accuracy of Chilaiditi's syndrome, CT imaging helps ensure better treatment decisions and outcomes for patients, promoting responsible, high-quality care.