Elevated Right Dome of diaphragm and Shortness of Breath

Patient Name: ABELMOSCHUS160017ESCULENTUS 

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A 67 years-old male presented with the complaint of shortness of breath while walking upstairs since last 4 months, which improves after taking rest. His symptom was non-progressive from the beginning of the symptom. His past medical history was significant for hypertension since last 4 years and surgical history for transurethral resection of the prostate (TURP) for Benign Prostatic Hyperplasia (BPH), left and right inguinal hernia surgery, and tonsillectomy at the age of 12. He was a non-smoker. 

On Examination, his Jugular venous pressure (JVP) was normal, no abnormal breath sounds heard. He had truncal obesity and gynecomastia. All routine blood investigations, liver function tests (LFTs) and urinary routine microscopic examination were within normal range except for elevated urine micro albumin of 2.0 mg/dl and urinary microalbumin creatinine ratio of 86.2 mcg/mg. His electro cardiogram (ECG) report showed sinus rhythm and echocardiography showed normal LV systolic function with the ejection fraction of 62%. 

Posterior-anterior view in the Chest X-Ray showed elevation in both the right and left dome of diaphragm along with radiolucent shadow under it. Subsequent right lateral view in the chest X-ray showed elevation in the right dome of the diaphragm. (Figure: 1 and 2)

Figure 1 (Posterior anterior view in CXR)

Figure 2 (Right Lateral view in CXR)

He was investigated further with tread mill test (TMT) where ST-segment changes was seen in aVL during peak exercise and recovery phase. (Figure: 3 and 4) 

Figure 3 (Tread mill test positive findings during peak exercise)

 

Figure 4 (Tread mill test positive findings during recovery phase)

Ultra sonogram (USG) of whole abdomen was done further to rule out diaphragmatic palsy. Ultra sonogram showed no paradoxical movement in diaphragm but was unable to show any clear structures under the right dome of diaphragm due to full of gas, and further evaluation in computed tomography (CT) scan of abdomen showed gas filled colonic loops between right hemidiaphragm and Liver. (Figure 5 & 6)

Figure 5 (Colonic loops interposed between right dome of diaphragm and liver)

Figure 6 (Colonic loops interposed between right dome of diaphragm and liver)

Discussion:

The colonic loops behind and above the liver and below the right dome of diaphragm was interpreted as Chelaiditi’s sign which needless to say was incidental but his actual cause of shortness of breath on unaccustomed exercise was defined by the tread mill test (TMT) that showed significant changes at peak exercise and recovery. This incidental radiological finding, when associated with clinical symptoms related to colonic interposition is called Chilaiditi's syndrome. ⁽¹⁾ Colonic interposition is often an asymptomatic radiologic finding and diagnosis is based on elevated right dome of diaphragm above liver by the intestine, distension of bowel by air, and depressed superior margin of the liver below the level of the left dome of diaphragm. Computed tomography scan is recommended to establish an accurate diagnosis, if radiograph or ultrasound cannot diagnose it clearly. ^{(2, 3)} 

^{Learning points:} 

• Elevated right dome of diaphragm can occur from diaphragmatic palsy but diagnosis of chilaiditi's sign should be considered as well when USG shows no positive findings for diaphragmatic palsy.
• Pneumoperitoneum and subphrenic abscess are two important differential diagnosis of this radiographic sign which can be excluded out when normal plicae circulares or haustral markings of the colon is seen under the right diaphragm. 
• The cause for shortness of breath was thought primarily due to stable angina on tread mill test positive finding but Chilaiditi's syndrome should also be considered as a cause for the shortness of breath as other cause found in this syndrome previously were abdominal pain, vomiting, constipation, angina-like chest pain.
• Chilaiditi’s sign is important to rule out in liver cirrhosis patients prior to percutaneous transhepatic procedure or liver biopsy to prevent complications.

 

References

1.      Saber AA, Boros MJ. Chilaiditi’s Syndrome: what should every surgeon know? The Am Surg 2005; 71(3):261-3.

2. Moaven O, Hodin RA. Chilaiditi Syndrome: a rare entity with important differential diagnoses. Gastroenterol Hepatol 2012; 8(4):276-8.

3.      Plorde JJ, Raker EJ. Transverse colon volvulus and associated Chilaiditi's syndrome: case report and literature review. Am J Gastroenterol. 1996; 91(12):2613-6.