Stesura Seveso 229Archivio Italiano di Urologia e Andrologia 2014; 86, 3 CASE REPORT A rare cause of renal colic pain: Chilaiditi syndrome Murat Tuncer, Cahit Sahin, Ozgur Yazici, Alper Kafkaslı, Kemal Sarica Dr. Lutfi Kirdar Training and Research Hospital Urology Clinic, Istanbul, Turkey. Chilaiditi syndrome, first described in 1910 by the radiologist Chilaiditi from Vienna, is the interposition of right colon between liver and right hemi diaphragm. It occurs most often in males and its incidence increases with age. It is often detected incidentally during radiological examination. It’s rarely symptomatic; symptoms can differ from mild abdominal pain to severe acute intestinal obstruction. Our case applied to emergency service with right flank pain. There was no calculus or dilatation in the urinary system at non-contrast abdominopelvic computerized tomogra- phy. Ascending colon was interposed between liver and diaphragm so that the patient was diagnosed as Chiliaditi syndrome. The patient was treated conserva- tively and discharged with dietary suggestions by the gastroenterology consultant. The conclusion of this report is that the Chilaiditi syndrome must be considered in differential diagnosis for patients presenting with urinary colic pain symptoms with no urinary pathology on radiologic imaging. KEY WORDS: Chilaiditi Syndrome; Renal colic; Hepatodiaphragmatic interposition. Submitted 3 February 2014; Accepted 30 June 2014 Summary CASE REPORT We present a patient with Chilaiditi syndrome referred to emergency department for severe right renal colic pain, who was diagnosed with the help of radiological exami- nations and treated conservatively. Case report details in Supplementary Materials post- ed on www.aiua.it DISCUSSION As in the majority of the cases of asymptomatic anatom- ical abnormalities, Chilaiditi’s sign is a characteristic radi- ological finding of hepatodiaphragmatic interposition of bowel segment. As Chiladiti syndrome has no specific clinical finding(s) which will let the clinician to consider the pathology at once and make the diagnosis, this pathology is usually incidentally diagnosed during a rou- tine chest and/or abdominal plain film (4) whereas CT and/or ultrasonography examination have been reported to be necessary for the differential diagnosis. Although No conflict of interest declared. the majority of the cases are clinically symptom free, in case of associated symptoms (abdominal pain, nausea, vomiting, distension, anorexia, constipation, respiratory distress and chest pain (2, 6, 7) it is called Chilaiditi syn- drome (8). The pathology is extremely rare and up to now approximately a total of 160 cases have been report- ed in the literature (9). In our present case radiological images were not obtained during an asymptomatic peri- od but CT evaluation done during symptomatic period confirmed the diagnosis. Hepatodiaphragmatic interposition of right colon is the most common radiological sign of Chiliaditi syndrome. Although an anterior interposition is the most common radiologic finding; posterior interposition is also possible in a certain percent of the cases (7). On the other hand, ileal or gastric form of interpositions have also been described in the literature (7). This condition may be permanent or temporary (10). Although the precise underlying causes of this patholog- ic interposition are still to be clarified, some liver (small or ptotic liver, cirrhosis, abnormal or deficient falciform ligament), diaphragm (diaphragmatic muscle degenera- tion, phrenic nerve palsy, and intrathoracic pressure increase due to tuberculosis or emphysema) and lastly colon related factors (abnormal dilatation of colon, abnormal or deficient suspensory ligament and congeni- tal malposition or malrotation of colon, chronic consti- pation, aerophagia) could be responsible for this anatomical abnormal location of the colon (2, 11). The differential diagnoses of Chilaiditi syndrome can also include bowel obstruction, volvulus, intussusception, ischemic bowel, or inflammatory conditions (eg, appen- dicitis or diverticulitis) and diaphragmatic hernia (2) pneumoperitoneum and subphrenic abcesses (12). In our case, at physical examination, lung auscultation was normal and there was no rebound or defence during abdominal palpation. Furthermore there were no signs of infection like fever and leucocytosis. In the light of the present clinical signs, symptoms and laboratory findings along with the normal anatomy of the gallbladder on CT (which may cause right upper quadrant abdominal pain), and absence of other characteristic radi- ologic signs which may be attributed to other well known pathologies (volvulus, intussusception, ischemic bowel or inflammatory conditions such as appendicitis or divertic- ulitis, etc.) and should be considered in differential diag- nosis we took in consideration this syndrome. Colonic DOI: 10.4081/aiua.2014.3.229 Tuncer CR_Stesura Seveso 08/10/14 12:19 Pagina 229 Archivio Italiano di Urologia e Andrologia 2014; 86, 3 M.Tuncer, C. Sahin, O. Yazici, A. Kafkaslı, K. Sarica 230 interposition between liver and diaphragm and the pres- ence of aforementioned symptoms, made us to diagnose the case as a Chilaiditi syndrome. This syndrome is generally asymptomatic however patients can refer with symptoms of abdominal pain, nau- sea, vomiting, distension, anorexia, constipation, respira- tory distress, cardiac arrhythmia (12). Occasionally, it may be associated with some severe complications such as internal hernias, colonic volvulus and acute intestinal obstruction (7). Treatment of Chilaiditi syndrome is generally conservative. This approach requires bed rest, nasogastric and/or rec- tal decompression, high fiber diet, fluid supplementation and stool softeners in symptomatic cases (7). Although conservative management is successful to relieve the existing symptoms in the majority of the cases, surgical treatment (such as subtotal colectomy, peritoneal fixation of colon, and hepatopexy) may be necessary in cases with persistent pain, refractory ileus, colonic volvulus or bowel ischemia (10, 13). Conservative management was successful in our case and the clinical course was uneventful without any serious complication. Chilaiditi syndrome generally presents with gastrointesti- nal, respiratory and cardiac symptoms. However, patients can rarely refer with symptoms mimicking renal colic pain as shown in our present case. To our knowl- edge there is only one case with this syndrome reported in the literature referring with renal colic symptoms (14) although another case has been reported to have urolog- ical problems such as complaints of prostatism and right renal stone (15). REFERENCES 1. Chilaiditi D. 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Hepatodiaphragmatic interposition of the colon: an unusual case of combined anterior and posterior types treated with an original operative technique. Dis Colon Rectum. 1999; 42:278-80. 8. Sorrentino D, Bazzocchi M, Badano L, et al. Heart-touching Chilaiditi’s syndrome. World J Gastroenterol. 2005; 11:4607-9. 9. Yagnik VD. Chilaiditi syndrome with carcinoma rectum. Saudi J Gastroenterol. 2011; 17:85-6. 10. Haddad CJ, Lacle J. Chilaiditi’s syndrome: a diagnostic chal- lange. Postgrad Med. 1991; 89:249-52. 11. White JJ, Chavez EP, Macon SJ. Internal hernia of the transverse colon Chilaiditi Syndrome in a child. J Pediatr Surg. 2002; 37:802-4. 12. Dogu F, Reisli I, Ikinciogullari A, et al. Unusual cause of respi- ratory distress: Chilaiditi syndrome. Pediatr Int. 2004; 46:188-90. 13. Hsu HL, Liu KL. Hepatodiphragmatic interposition of the colon.CMAJ. 2011; 183:132. 14. Alva S, Shetty-Alva N, Longo WE. Image of the month. Chilaiditi sign or syndrome.Arch Surg 2008; 143:93-4. 15. Özer C, Zenger S. Chilaiditi syndrome in a patient with urolog- ical problems: Incidental diagnosis on computed tomography. Can Urol Assoc J. 2012; 6:75-6. Interposition of colon between diaphragm and liver: the Chilaiditi sign. Correspondence Murat Tuncer, MD (Corresponding Author) murattuncer77@hotmail.com. Cahit Sahin, MD cahitsahin129@hotmail.com Ozgur Yazici, MD md.ozguryazici@yahoo.com.tr Alper Kafkaslı, MD alpkafkasli@hotmail.com Kemal Sarıca, MD Professor saricakemal@gmail.com Altunizade mah.Atif bey sok.Gokdeniz sitesi E blok D:20 Kosuyolu, Istanbul, Turkey Tuncer CR_Stesura Seveso 08/10/14 12:19 Pagina 230