Chilaiditi syndrome mimicking congestive heart failure.

Okiro JO. BMJ Case Rep 2017. doi:10.1136/bcr-2017-220811 Description An 85-year-old man presented with orthopnoea and dyspnoea, symptoms of which were suspicious for heart failure. He was in respiratory distress and oxygen saturation was 85% on 4 L oxygen. On initial assessment, lungs were clear and heart sounds were normal. What was immediately evident was a distended abdomen. Digital rectal examination revealed hard faeces in rectum. He had a history of chronic constipation and last bowel movement was over 5 days ago. Chest X-ray (figure 1) showed raised diaphragms with loops of large bowel interposed between the right hemidiaphragm and liver. An abdominal X-ray (figure 2) confirmed faecal impaction. Brain natriuretic peptide, d-dimer and echocardiogram were normal. He eventually underwent manual evacuation following failure of oral laxatives and enemas (figure 3 for follow-up chest X-ray). This chest X-ray shows Chilaiditi sign (CS), a rare anomaly where bowel lies between the liver and right diaphragm. CS may be congenital or acquired. Chronic constipation is a recognised cause of acquired CS. Other acquired causes are cirrhosis, raised intra-abdominal pressure and diaphragmatic paralysis. CS is asymptomatic but when causing symptoms, the term Chilaiditi syndrome is used. Chilaiditi syndrome is a great mimicker since patients may present with signs and symptoms that imitate various medical and surgical emergencies. Initial chest X-ray showed our patient’s lungs critically compressed by the distended loops of bowel