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An Unusual Cause of Right Upper Quadrant Pain and Emesis
The Journal of Emergency Medicine, Vol. -, No. -, pp. 1–3, 2014 Copyright Ó 2014 Elsevier Inc. Printed in the USA. All rights reserved 0736-4679/$ - see front matter
http://dx.doi.org/10.1016/j.jemermed.2014.02.007
Visual Diagnosis in Emergency Medicine
AN UNUSUAL CAUSE OF RIGHT UPPER QUADRANT PAIN AND EMESIS Shankar LeVine, MD, Bradley Ching, MD, and Barry Simon, MD Department of Emergency Medicine, Highland Hospital at Alameda County Medical Center, Oakland, California Reprint Address: Shankar LeVine, MD, Department of Emergency Medicine, Alameda County Medical Center, 1411 East 31st Street, Oakland, CA 94602
point with an air fluid level suggestive of a partial small bowel obstruction (SBO). This patient was admitted to the general surgery service for observation. After failing a trial of conservative treatment for the partial SBO with bowel decompression, she underwent a diagnostic laparoscopy. This revealed distended loops of small bowel and inflammatory adhesions between the liver and anterior abdominal wall.
INTRODUCTION Patients often present to the emergency department (ED) with nonspecific symptoms requiring careful evaluation to make the infrequent rare diagnosis. Chilaiditi sign and syndrome is particularly interesting, as it presents either as an incidental radiographic finding or, in the right clinical setting, the etiology of a patient’s symptoms. CASE REPORT A 43-year-old otherwise healthy female presented to the ED with approximately 8 h of intermittent sharp right upper quadrant (RUQ) abdominal pain, nausea, and vomiting. Her vital signs were unremarkable and physical examination revealed a middle-aged female in moderate distress due to pain. She had RUQ tenderness with a positive Murphy’s sign. Laboratory studies including complete blood count, complete metabolic panel, and lipase were within normal limits. The patient underwent a bedside RUQ ultrasound (US) (Figure 1) followed by computed tomography (CT) (Figures 2 and 3) of the abdomen and pelvis. The US revealed a hypoechoic structure between the diaphragm and liver without peristalsis on multiple views and cholelithiasis without evidence of cholecystitis. The CT confirmed the suspicion that this structure was the small bowel crossing between the diaphragm and the liver, also revealing a transition
Figure 1. Single image from bedside sonogram of the patient’s right upper quadrant revealing a hypoechoic structure between the diaphragm and liver consistent with bowel. A single prominent gallstone is seen without signs of an acute infection, such as gallbladder wall thickening or pericholecystic fluid.
RECEIVED: 12 February 2013; FINAL SUBMISSION RECEIVED: 23 January 2014; ACCEPTED: 10 February 2014 1
2
S. LeVine et al.
Figure 3. Single coronal slice from the patient’s computed tomography abdomen and pelvis demonstrates the gallstone visualized by the ultrasound without any evidence of cholecystitis. Figure 2. Single coronal slice from the patient’s computed tomography abdomen and pelvis reveals the small bowel crossing between the diaphragm and the liver.
The adhesions were taken down and bowel was run, thereby reducing the SBO. Additionally, a cholecystectomy was performed. DISCUSSION Chilaiditi syndrome is an uncommon condition in which the small or large bowel is interposed between the liver and the diaphragm and the patient experiences symptoms related to this interposition (1). The estimated incidence is 0.025%–0.28% in the general population. On imaging, a loop of bowel can be visualized between the liver and hemi-diaphragm (known as Chilaiditi sign). The incidence of Chilaiditi sign is estimated between 0.1% and 1% of the general population. It can be seen on chest x-ray or, as demonstrated in this case, on the bedside US (Figure 1), and can be easily mistaken for pneumoperitoneum. On chest x-ray, visualization of haustra or plicae circulares above the liver can assist in this distinction, however, these are often not seen. The dynamic nature of bedside US can be used to make this distinction. In Chilaiditi sign, repositioning the patient during US does not significantly change the position of the gas echo in contrast to the freely mobile air seen in pneumoperitoneum. Additionally, with prolonged scanning and close observation, peristalsis can be visualized in Chilaiditi sign. These maneuvers help reveal that the finding of air
between the diaphragm and liver is consistent with pseudopneumoperitoneum rather than free intraperitoneal air (pneumoperitoneum) (2). Ultimately, in a hemodynamically stable patient with diagnostic uncertainty, a CT is recommended, as was done in this case (Figure 2) (3). Patients with Chilaiditi syndrome can present with a variety of symptoms. The most common are gastrointestinal symptoms, such as abdominal pain, constipation, and vomiting, less frequent are respiratory distress or chest pain (3). The differential diagnosis can include but is not limited to bowel obstruction, ischemic bowel, biliary disease, or inflammatory conditions, such as appendicitis or diverticulitis. As in this case, ultimately the diagnostic uncertainly among SBO, Chilaiditi syndrome, or biliary colic, and the persistence of symptoms, can result in a diagnostic laparoscopy. However, the majority of cases of Chilaiditi syndrome resolve spontaneously or with bowel decompression and only in some cases is operative management necessary (1). There are several complications of this rare syndrome, including development of internal hernias, bowel ischemia, intestinal volvulus, or obstruction. CONCLUSIONS Chilaiditi syndrome is an uncommon and challenging diagnosis that emergency physicians should be aware of and consider in patients presenting with a variety of symptoms, including abdominal pain, vomiting, or even
Chilaiditi Syndrome
shortness of breath. As demonstrated in this case, the finding of air under the diaphragm on either chest radiograph or during bedside abdominal US requires careful evaluation to discern whether this represents an acute surgical emergency, an incidental finding, or the etiology of the patient’s symptoms.
3
REFERENCES 1. Saber A, Boros M. Chilaiditi’s syndrome: what should every surgeon know? Am Surg 2005;71:261–3. 2. Hoffmann B, Nurnberg D. Focus on abnormal air: diagnostic ultrasonography for the acute abdomen. Eur J Emerg Med 2012;19:284–91. 3. Moaven O, Hodin R. Chilaiditi syndrome: a rare entity with important differential diagnosis. Gastroenterol Hepatol 2012;8:276–8.
http://dx.doi.org/10.1016/j.jemermed.2014.02.007
Visual Diagnosis in Emergency Medicine
AN UNUSUAL CAUSE OF RIGHT UPPER QUADRANT PAIN AND EMESIS Shankar LeVine, MD, Bradley Ching, MD, and Barry Simon, MD Department of Emergency Medicine, Highland Hospital at Alameda County Medical Center, Oakland, California Reprint Address: Shankar LeVine, MD, Department of Emergency Medicine, Alameda County Medical Center, 1411 East 31st Street, Oakland, CA 94602
point with an air fluid level suggestive of a partial small bowel obstruction (SBO). This patient was admitted to the general surgery service for observation. After failing a trial of conservative treatment for the partial SBO with bowel decompression, she underwent a diagnostic laparoscopy. This revealed distended loops of small bowel and inflammatory adhesions between the liver and anterior abdominal wall.
INTRODUCTION Patients often present to the emergency department (ED) with nonspecific symptoms requiring careful evaluation to make the infrequent rare diagnosis. Chilaiditi sign and syndrome is particularly interesting, as it presents either as an incidental radiographic finding or, in the right clinical setting, the etiology of a patient’s symptoms. CASE REPORT A 43-year-old otherwise healthy female presented to the ED with approximately 8 h of intermittent sharp right upper quadrant (RUQ) abdominal pain, nausea, and vomiting. Her vital signs were unremarkable and physical examination revealed a middle-aged female in moderate distress due to pain. She had RUQ tenderness with a positive Murphy’s sign. Laboratory studies including complete blood count, complete metabolic panel, and lipase were within normal limits. The patient underwent a bedside RUQ ultrasound (US) (Figure 1) followed by computed tomography (CT) (Figures 2 and 3) of the abdomen and pelvis. The US revealed a hypoechoic structure between the diaphragm and liver without peristalsis on multiple views and cholelithiasis without evidence of cholecystitis. The CT confirmed the suspicion that this structure was the small bowel crossing between the diaphragm and the liver, also revealing a transition
Figure 1. Single image from bedside sonogram of the patient’s right upper quadrant revealing a hypoechoic structure between the diaphragm and liver consistent with bowel. A single prominent gallstone is seen without signs of an acute infection, such as gallbladder wall thickening or pericholecystic fluid.
RECEIVED: 12 February 2013; FINAL SUBMISSION RECEIVED: 23 January 2014; ACCEPTED: 10 February 2014 1
2
S. LeVine et al.
Figure 3. Single coronal slice from the patient’s computed tomography abdomen and pelvis demonstrates the gallstone visualized by the ultrasound without any evidence of cholecystitis. Figure 2. Single coronal slice from the patient’s computed tomography abdomen and pelvis reveals the small bowel crossing between the diaphragm and the liver.
The adhesions were taken down and bowel was run, thereby reducing the SBO. Additionally, a cholecystectomy was performed. DISCUSSION Chilaiditi syndrome is an uncommon condition in which the small or large bowel is interposed between the liver and the diaphragm and the patient experiences symptoms related to this interposition (1). The estimated incidence is 0.025%–0.28% in the general population. On imaging, a loop of bowel can be visualized between the liver and hemi-diaphragm (known as Chilaiditi sign). The incidence of Chilaiditi sign is estimated between 0.1% and 1% of the general population. It can be seen on chest x-ray or, as demonstrated in this case, on the bedside US (Figure 1), and can be easily mistaken for pneumoperitoneum. On chest x-ray, visualization of haustra or plicae circulares above the liver can assist in this distinction, however, these are often not seen. The dynamic nature of bedside US can be used to make this distinction. In Chilaiditi sign, repositioning the patient during US does not significantly change the position of the gas echo in contrast to the freely mobile air seen in pneumoperitoneum. Additionally, with prolonged scanning and close observation, peristalsis can be visualized in Chilaiditi sign. These maneuvers help reveal that the finding of air
between the diaphragm and liver is consistent with pseudopneumoperitoneum rather than free intraperitoneal air (pneumoperitoneum) (2). Ultimately, in a hemodynamically stable patient with diagnostic uncertainty, a CT is recommended, as was done in this case (Figure 2) (3). Patients with Chilaiditi syndrome can present with a variety of symptoms. The most common are gastrointestinal symptoms, such as abdominal pain, constipation, and vomiting, less frequent are respiratory distress or chest pain (3). The differential diagnosis can include but is not limited to bowel obstruction, ischemic bowel, biliary disease, or inflammatory conditions, such as appendicitis or diverticulitis. As in this case, ultimately the diagnostic uncertainly among SBO, Chilaiditi syndrome, or biliary colic, and the persistence of symptoms, can result in a diagnostic laparoscopy. However, the majority of cases of Chilaiditi syndrome resolve spontaneously or with bowel decompression and only in some cases is operative management necessary (1). There are several complications of this rare syndrome, including development of internal hernias, bowel ischemia, intestinal volvulus, or obstruction. CONCLUSIONS Chilaiditi syndrome is an uncommon and challenging diagnosis that emergency physicians should be aware of and consider in patients presenting with a variety of symptoms, including abdominal pain, vomiting, or even
Chilaiditi Syndrome
shortness of breath. As demonstrated in this case, the finding of air under the diaphragm on either chest radiograph or during bedside abdominal US requires careful evaluation to discern whether this represents an acute surgical emergency, an incidental finding, or the etiology of the patient’s symptoms.
3
REFERENCES 1. Saber A, Boros M. Chilaiditi’s syndrome: what should every surgeon know? Am Surg 2005;71:261–3. 2. Hoffmann B, Nurnberg D. Focus on abnormal air: diagnostic ultrasonography for the acute abdomen. Eur J Emerg Med 2012;19:284–91. 3. Moaven O, Hodin R. Chilaiditi syndrome: a rare entity with important differential diagnosis. Gastroenterol Hepatol 2012;8:276–8.