Volume X, no. 4 : November 2009 250 Western Journal of Emergency Medicine
images in emergency medicine
Rosa F. McNamara, MCEM, MRCSEd(A&E), MRCPI*
Stephen Cusack, FCEM, FRCSEd(A&E)*
Patrick Hallihan, MRCS†
* Cork University Hospital, Emergency Department, Wilton, Cork, Ireland
† Cork University Hospital, Department of Surgery, Wilton, Cork, Ireland
Supervising?Section?Editor: Sean Henderson, MD
Submission history: Submitted September 29, 2009; Accepted October 8, 2009
Reprints available through open access at http://escholarship.org/uc/uciem_westjem
A 58-year-old man presented to the Emergency
Department with a two-day history of vomiting, diarrhea
and intermittent central abdominal pain. His background
history was significant for peptic ulcer disease. On
examination there was diffuse abdominal tenderness, and
a fecal occult blood test was positive. A departmental
chest radiograph had appearances suggestive of a
pneumoperitoneum, with an elevated right hemidiaphragm
and subdiaphragmatic free air. The patient was referred to
the surgical team for management of a suspected perforated
Subsequent CT imaging of thorax and abdomen revealed
hepato-diaphragmatic interposition of the transverse colon,
as well as extensive colitis. He was managed conservatively
and discharged home well after four days.
Chilaiditi’s sign is the appearance of free air under the
diaphragm caused by interposition of the transverse colon
between the liver and diaphragm. It is usually asymptomatic
and is an incidental finding. It is estimated to occur in 0.25%
to 0.28% of the general population1 and was first described
by Demetrious Chilaiditi in 1910.2 When the sign is observed
in association with symptoms such as abdominal pain or
vomiting it is termed Chilaiditi’s syndrome. It is in this
scenario that the radiographic findings may be mistaken for
pneumoperitoneum, as occurred in this case.
Address?for?Correspondence: Rosa McNamara, MRCPI,
MRCSEd(A&E), MCEM. Department of Emergency
Medicine,Cork University Hospital, Wilton, Cork,Ireland. Email
Risaliti A, DeAnna D, Terrosu G, et al. Chilaiditis’s syndrome 1.
as a surgical and non surgical problem. Surg Gynecol Obstet.
Chilaiditi D. Zur Frage der Hapatoptose und Ptose in allgemeinen im 2.
Auschluss an drei FŠlle von temporŠrer partieller Leberverlagerung.
Fortschritte auf dem Gebiete der Roentgenstrahlen. 1910;11:173-208.
Figure. Chest radiograph suggestive of a pneumoperitoneum, with
an elevated right hemidiaphragm and subdiaphragmatic free air.