Chilaiditi sign: why are clinical findings more important in ED?

Chilaiditi sign is a radiographic term used when the hepatic flexure of the colon is seen interposed between the liver and right hemidiaphragm. When symptomatic, this is Chilaiditi syndrome. It is mostly diagnosed as an incidental finding on a chest roentgenogram or abdominal computed tomography (CT), which can be present temporarily or permanently. A 52-year-old man presented to the emergency department with abdominal pain that began abruptly 4 hours before presentation. On examination, epigastric tenderness was present, but there were no defense and rebound tenderness. In addition, abdomen was soft. Chest radiography suggested the presence of air below the right side of the diaphragm. Subsequent CT revealed the presence of subphrenic interposition of the colon above the liver. These findings suggested Chilaiditi syndrome. The patient was managed conservatively with pain management and intravenous fluid hydration. During follow-up in hospital, his abdominal pain resolved without surgical intervention. It is important for physicians to be able to distinguish pneumoperitoneum and pseudopneumoperitoneum to allow proper diagnosis and treatment. Emergent laparotomy should be delayed, and a CT scan should be done first.