A strange case of epigastric pain: chilaiditi’s syndrome

BACKGROUND Chilaiditi’s syndrome (CS) is a rare syndrome with an incidence of 0.025%–0.28%, described for the first time by D.Chilaiditi in 1910. Chilaiditi’s sign is characterised by a hepato-diaphragmatic interposition of the bowel. Chilaiditi’s sign is called CS when it is accompanied by symptoms such as abdominal pain, nausea, vomiting, constipation and also respiratory distress. Risk factor for CS are congenital anatomic variations in abdomen and anatomic distortions result of functional disorders (obesity, chronic lung diseases). In differential diagnoses pneumoperitoneum, subphrenic abscess and diaphragmatic hernia have to be excluded. If initial ultrasound or X-ray is unclear, a CT scan can clarify the doubt of the diagnosis. CS is usually a benign process, treated with conservative therapy. However cases described in literature developed with severe complications (perforation, mesentery ischemia, bowel obstruction and death). In case of complications surgery is indicated. CASE REPORT A 14-years-old female with history of obesity, constipation and abdominal bloating was admitted in our Department with epigastric pain, nausea and repeated vomiting. No relevant family history was traced from the interview. Clinical examination revealed increasing epigastric pain after abdominal palpation and intestinal meteorism. Murphy’s sign was positive.Initial laboratory investigations included blood counts, liver and renal function tests, serum electrolytes, CRP and sed rate, resulted all within the normal range. Subsequently, anti-transglutaminase antibodies and Faecal Occult Blood Test were tested, both resulted negative.According with the persistence of symptoms, faecal H.Pylori was investigated, without no positivity. Finally abdomen ultrasound showed a hepato-diaphragmatic interposition of small intestine. The correct diagnosis was CS. ConclutionS Few cases of paediatric patients with CS are described in literature. Our patient had obesity as risk factor:according to her history and physical examination, acute gastritis, H.Pylori’s infection and acute cholecystitis were considered as possible diagnoses. Finally abdomen ultrasound clarified the diagnosis. Our patient was treated with conservative management: esomeprazole, high fibre diet and recommendations in order to lose weight.