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Figura 1. Tomografía Computarizada de tórax (corte coronal). Se observan ambos campos pulmonares y las cavidades cardiacas. La flecha roja señala el área hipodensa ovalada correspondiente al aire dentro de un asa de colon interpuesta entre el hemidiafragma derecho (línea hiperdensa arriba) y el borde superior del hígado (abajo), causando una depresión del borde superior del hígado. Fuente: tomada de la historia clínica, previa autorización del paciente.

Figure 1. Chest Computed Tomography Scan (coronal plane) Both lung fields and cardiac chambers are observed. The red arrow indicates the oval hypodense area corresponding to the air inside the loop of colon interposed between the right hemidiaphragm (hyperdense line up) and superior border of the liver (down), causing a depression of the superior border of the liver. Source: taken with authorization from the patient's medical record.

Figura 1. Tomografia Computadorizada de tórax (corte coronal). Observam-se ambos os campos pulmonares e as cavidades cardíacas. A seta vermelha aponta para a área hipodensa oval correspondente ao ar dentro de uma alça do cólon interposta entre o hemidiafragma direito (linha hiperdensa acima) e a borda superior do fígado (abaixo), causando uma depressão da borda superior do fígado. Fonte: obtida com permissão do histórico clínico do paciente.

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RESUMEN El síndrome de Chilaiditi es un hallazgo radiográfico poco frecuente. Consiste en la interposición de un asa intestinal entre el hígado y el diafragma. No existe etiología claramente establecida aunque se han planteado varias hipótesis que explican su aparición. Se presenta el caso de un paciente de sexo masculino, de 81 años que ingresó con náuseas, vómitos, dolor abdominal, ansiedad y polipnea. Se encontró en el ionograma hiponatremia con sodio sérico en 128 meq/l. La radiografía de tórax mostró aire debajo del hemidiafragma, la tomografía de tórax y abdomen encontró presencia de interposición colónica entre el hígado y el hemidiafragma derecho, imitando la presencia de aire libre. Se confirmó síndrome de Chilaiditi. El paciente fue tratado con un manejo conservador, con suspensión de la vía oral y colocación de sonda nasogástrica. Se presenta el caso por lo raro de esta entidad y porque su diagnóstico es importante para evitar someter al paciente a una intervención quirúrgica.

ABSTRACT Chilaiditi syndrome is a rare radiographic finding. It consists of the interposition of an intestinal loop between the liver and the diaphragm. There is no clearly established etiology, although various hypotheses have been put forward to explain its presence. The case of an 81-year-old male patient who was admitted with nausea, vomiting, abdominal pain, anxiety, and polypnea is presented. Serum sodium hyponatremia was found on the ionogram at 128 meq / l. The chest radiograph showed air below the hemidiaphragm, the chest and abdomen tomography found the presence of colonic interposition between the liver and the right hemidiaphragm, imitating the presence of free air. Chilaiditi syndrome was confirmed. The patient was treated with conservative management, with suspension of the oral route and placement of a nasogastric tube. The case is presented due to the rareness of this entity and because its diagnosis is important to avoid undergo the patient to surgical intervention.

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Resumen Hombre de 70 años de edad, quien ingresó en el área de urgencias con antecedente de atropellamiento. Refería dolor torácico bilateral y disnea. Al examen físico lo encontramos con vía aérea permeable, ausencia de murmullo vesicular en porción inferior de hemitórax derecho asociada con pérdida de la matidez hepática, hemodinámicamente estable, consciente, con puntaje de 15 en la escala de coma de Glasgow. Se obtuvo radiografía de tórax, la cual reveló una imagen radiolúcida por encima del hígado, por lo cual se solicitó tomografía de abdomen con contraste, la que permitió corroborar la integridad del diafragma. Este tipo de imagen radiológica puede sugerir una ruptura diafragmática traumática; sin embargo, sólo se trata de un hallazgo radiográfico.

Abstract A 70-year-old male entered the emergency department after being hit by a car. He had bilateral thoracic pain and dyspnea. On the physical examination we found him with patent airway, absence of vesicular murmur in the lower portion of the right hemithorax in association with loss of hepatic dullness, hemodinamic stability, conscious with 15 points on the Glasgow coma scale. We obtained a plain thoracic x-ray, which revealed a radiolucent image over the liver; for that reason, we obtained a contrasted CT-scan which showed diaphragmatic integrity. This image finding may suggest a traumatic diaphragmatic rupture; however, it may be only a radiological finding.

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Resumen El signo de Chilaiditi es un hallazgo radiográfico infrecuente que consiste en la interposición de un asa intestinal entre el hígado y el diafragma. No existe etiología claramente establecida; sin embargo, se han planteado varias hipótesis que explican su presencia, entre ellos la hiperlaxitud de los ligamentos suspensorios del hígado, el aumento de la presión intraabdominal y la redundancia colónica. Al asociarse este hallazgo con síntomas gastrointestinales o respiratorios se denomina síndrome de Chilaiditi, y su tratamiento principalmente es sintomático, en casos excepcionales requiere abordaje quirúrgico. Este signo se encuentra usualmente de manera incidental y se ha visto una relación con enfermedad respiratoria crónica; pudiendo afectar su curso clínico, motivando a profundizar en el estudio integral. Se presenta el caso de un paciente adulto mayor, en seguimiento médico por enfermedad pulmonar obstructiva crónica, cuya radiografía de tórax evidencia la interposición de un asa intestinal entre la cúpula diafragmática derecha y el hígado. MÉD.UIS. 2018;31(3):57-61.

Abstract The Chilaiditi sign is a rare radiographic finding, which consists in the interposition of an intestinal handle between the liver and the diaphragm. There is no clear etiology established, however, several hypotheses have been proposed to explain its presence, including the hyper-laxity of the liver suspensory ligaments, an increase on the intra-abdominal pressure and colonic redundancy. When this finding is associated with gastrointestinal or respiratory symptoms is called "Chilaiditi syndrome", and its treatment is mainly symptomatic; in exceptional cases a surgical approach is required. The Chilaiditi sign is usually an incidental finding, and a connection with chronic respiratory disease has been seen, and it could affect this pathology's clinical course, being this a motivation to deepen in an integral study. We present a case of an elder patient, being followed due to chronic obstructive pulmonary disease, whose chest X-ray shows interposition of an intestinal handle between the right diaphragmatic dome and the liver. MÉD.UIS. 2018;31(3):57-61.

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O autor apresenta um caso de "sinal de Chilaiditi" em mulher com manifestação radiológica e assintomática. É condição benigna e apenas sinal se assintomática ou síndrome caso contrário, com manifestações clínicas na área. Raramente configura-se indicação cirúrgica. O correto diagnóstico é importante pois evita-se conduta inadequada, principalmente se a indicação for cirúrgica e de caráter emergencial, como abdome agudo (pneumoperitônio, abcesso subfrênico) ou pneumotórax

The author presents a case of "Chilaiditi sign" in a woman with radiological and asymptomatic manifestations. It is a benign condition and only sign if asymptomatic or otherwise syndrome with clinical manifestations in the area. Surgical recommendation is rarely present. Correct diagnosis is important because inappropriate conduct is avoided, specially if surgical and emergency indication such as acute abdomen (pneumoperitoneum, subphrenic abscess) or pneumothorax

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The interposition of a portion of the colon between the liver and the diaphragm is called Chilaiditi sign and discovered incidentally during radiological study for other reasons and usually asymptomatic presentation. When the discovery is accompanied by clinical symptoms such as abdominal pain, nausea, vomiting, bloating, constipation called Chilaiditi Syndrome. The Chilaiditi sign is a very rare condition, and the Chilaiditi syndrome is even more, especially if associated with other acute diseases. We report the case of a man of 41 years was admitted with right upper quadrant abdominal pain, nausea, vomiting, difficulty was diagnosed with radiographic and tomographic images making the differential diagnosis with lung abscess and diaphragmatic hernia. The final diagnosis was Chilaiditi Syndrome associated with acute pancreatitis and penumonia.

La interposición de una parte del colon entre el hígado y el diafragma se llama signo de Chilaiditi, el cual se descubre de forma casual durante un estudio radiológico por otra causa. Su presentación suele ser asintomática. Cuando el hallazgo se acompaña de síntomas clínicos como dolor abdominal, náuseas, vómito, distensión abdominal o estreñimiento se llama síndrome de Chilaiditi. El signo de Chilaiditi es muy raro y aún lo es más el síndrome de Chilaiditi, sobre todo si se asocia con otras patologías agudas. Se presenta el caso clínico de un hombre de 41 años de edad que ingresó por dolor abdominal en el hipocondrio derecho, náuseas y vómito; hubo dificultad diagnóstica ante las imágenes radiológicas y tomográfícas, por lo que se hizo el diagnóstico diferencial con absceso pulmonar y hernia diafragmática. El diagnóstico final fue síndrome de Chilaiditi asociado a pancreatitis y neumonía.

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Aunque poco frecuente, la interposición de intestino entre el diafragma y el hígado, signo o síndrome de Chilaiditi (en relación a la ausencia o presencia de síntomas gastrointestinales), constituye una condición clínica de importancia dadas las posibilidades de diagnóstico diferencial, tales como: neumoperitoneo, hernia diafragmática y absceso subfrénico. OBJETIVO: Presentar dos preescolares con signo y síndrome de Chilaiditi, así como resaltar la importancia de esta condición clínica. CASOS CLÍNICOS: Caso 1: Preescolar varón evaluado por cuadro respiratorio sin síntomas abdominales. La radiografía de tórax mostró infiltrados retrocardíacos izquierdos y presencia de aire en región subdiafragmática derecha. En radiografías previas se encontraba la misma imagen. Se concluyó que se trataba de un signo de Chilaiditi asociado a un cuadro de neumonía, se trató con antibioterapia y se dio de alta. Caso 2: Preescolar de sexo femenino, evaluada por distensión abdominal y constipación. Radiografía de tórax, solicitada previamente por cuadro respiratorio, con imagen de colon derecho situado entre el hemidiafragma y el hígado. Enema baritado de colon confirmó los hallazgos. Exámenes de laboratorio normales. Se concluyó síndrome de Chilaiditi, se indicó tratamiento médico, con buena evolución. CONCLUSIÓN: Se resalta la importancia de esta condición clínica que pese a ser infrecuente constituye un reto diagnóstico en los servicios de urgencia.

Although infrequent, bowel interposition between diaphragm and liver, Chilaiditi’s sign or syndrome (without or with gastrointestinal symptoms), are a major clinical condition given the possibilities of differential diagnosis, such as pneumoperitoneum, diaphragmatic hernia and subphrenic abscess. Objective: To report the cases of two preschool patients with Chilaiditi´s sign and syndrome, as well as to highlight the importance of this clinical condition. Clinical cases: Case 1: A male preschooler evaluated by respiratory disease without abdominal symptoms. Thorax X-ray shows left retrocardiac infiltrates and air in right subdiaphragmatic region. Previous radiographies shows the same image. He was diagnosed with Chilaiditi sign associated with pneumonia, antibiotics were used before discharge. Case 2: A female preschooler, evaluated by abdominal distention and constipation. A previous thorax X-ray shows bowel interposition between diaphragm and liver. Barium enema confirmed the findings. Blood test were normal. A Chilaiditi's syndrome was diagnosed. She received medical treatment with favorable evolution. Conclusion: These cases highlight the importance of this clinical condition that, despite being infrequent, constitutes a diagnostic challenge in the emergency services.

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Embora a síndrome de Ogilvie ou pseudo-obstrução intestinaltenha sido poucas vezes relatada, não se trata decondição muito rara. Relata-se o estudo de caso de umamulher de 85 anos com hipocalemia em que os principaisaspectos são enfatizados, com o objetivo de aumentar oíndice de suspeita sobre essa entidade. O diagnóstico diferencialentre as síndromes de Ogilvie e de Chilaiditi érealçado, em virtude dos aspectos comuns a essas duascondições. A paciente recebeu suporte clínico geral e reposiçãohidroeletrolítica com bom resultado, após quatrodias de tratamento conservador. O diagnóstico precoce e a pronta correção de fatores predisponentes contribuírampara o sucesso do manuseio clínico da síndrome deOgilvie que afetou essa frágil paciente.

Although Ogilvie?s syndrome, or intestinal pseudoobstruction,has been scarcely reported, it is not arare condition. With the objective of raising awarenessabout this entity, the case study of an 85-yearoldwoman with hypokalaemia is reported and themain findings are emphasised. The differential diagnosisbetween Ogilvie?s and Chilaiditi syndromeis highlighted because of the features shared bythese conditions. The patient received general clinicalsupport and her hydro-electrolyte balance wasmaintained, with a good outcome after four days ofconservative treatment. Early diagnosis and promptcorrection of predisposing factors contributed tothe successful clinical management of the Ogilvie?ssyndrome affecting this fragile elderly patient.

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Os autores apresentam um caso de síndrome de Chilaiditi em uma mulher de 56 anos de idade. Mesmo tratando-se de condição benigna com rara indicação cirúrgica, reveste-se de grande importância pela implicação de urgência operatória que representa o diagnóstico equivocado de pneumoperitônio nesses pacientes. É realizada revisão da literatura, com ênfase na fisiopatologia, propedêutica e tratamento desta entidade.

The authors report a case of Chilaiditi's syndrome in a 56-year-old woman. Although this is a benign condition with rare surgical indication, it has great importance for implying surgical emergency in cases where such condition is equivocally diagnosed as pneumoperitoneum. A literature review is performed with emphasis on pathophysiology, diagnostic work-up and treatment of this entity.

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A interposição permanente ou temporária do cólon, intestino delgado ou estômago no espaço hepatodiafragmático é conhecido como sinal de Chilaiditi, sendo geralmente assintomático. É evidenciado normalmente em um exame radiológico de rotina. A sua incidência é de 0,025% nos exames radiológicos em todas as idades, aumentando levemente nos pacientes maiores de 60 anos, sendo mais comuns em homens do que em mulheres, com uma relação de 4:1. A associação do sinal de Chilaiditi com sintomas como dor abdominal, náuseas, volvo intestinal, dor retroesternal, sintomas respiratórios, vômitos, distensão abdominal, obstrução ou suboclusão intestinal caracteriza a síndrome de Chilaiditi. No presente estudo, apresentamos um novo caso do sinal de Chilaiditi observado ocasionalmente ao exame radiológico de abdome (AU)

The permanent or temporary interposition of the colon, small intestine or stomach in between the liver and the diaphragm is known as Chilaiditi's sign, usually being asymptomatic. The condition is usually diagnosed in routine X-rays. Its incidence is 0.025% in radiological scans in all age groups, with a slight increase in patients over 60. It is more common in males than females in a ratio of 4:1. The association of Chilaiditi's sign with symptoms of abdominal pain, nausea, intestinal volvus, retrosternal pain, respiratory symptoms, vomiting, abdominal distension, intestinal obstruction or sub-occlusion characterizes the Chilaiditi syndrome. Here we report the case of Chilaiditi's sign as detected in abdominal X-rays (AU)

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Se presenta el caso de un hombre de 60 años de edad, que consulta por presentar flatulencia, sensación de saciedad, dispepsia, y dolor abdominal, en el que se encontró, en una tomografía abdominal, el signo de Chilaiditi, el cual puede presentar síntomas y convertirse en un Síndrome o mantenerse asintomático y que debe ser tomado en cuenta en el diagnóstico diferencial, ya que puede confundirse con un neumoperitonio u otras entidades nosológicas.

We present the case of a 60-year old man with symptoms of flatulence, fullness, satiety sensation, dyspepsia and abdominal pain, in whom we found, in a abdominal tomography, chilaiditi sign, which can present symptoms and turn into a syndrome or remain asymptomatic and should be taken into account in the differential diagnosis as it can be confused with a pneumoperitoneum or other nosological entities.

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