1. Chilaiditi Sign By Borko Kereshi, MSIII

2. The case History: 58 yo female with right upper pole kidney mass – Found to be Renal Cell Carcinoma – Surgical history of a Roux-en-Y gastric There was an incidental finding…

3. What’s going on?

7. How does this happen? Colon can roll over on its edge, separating the liver from the anterior abdominal wall – Causes the liver to appear smaller when percussed Internal displacements due to irregular intestinal adhesions can arise during intra-uterine or extra- uterine life Mobility of the entire ascending colon secondary to defective fusion allows the right colon to be located anywhere in the abdomen including beneath the right diaphragm

8. Chilaiditi’s Sign usually asymptomatic interposition of the bowel (usually hepatic flexure of the colon) between the liver and the (right) hemidiaphragm Seen in 0.1-0.25% of chest x-rays Not to be mistaken for pneumoperitoneum

9. Chilaiditi’s Sign, contributing factors – Absence of normal suspensory ligaments of the transverse colon – Abnormality or absence of the falciform ligament – Redundant colon, as might be seen with chronic constipation or in bedridden individuals – Aerophagia – Paralysis or eventration of the right hemidiaphragm – Patients with chronic lung disease, cirrhosis and ascites

10. Coronal view

12. Sagittal View

13. Renal Cell carcinoma

15. References Samuel Wilks, Walter Moxon. Lectures on Pathological Anatomy. 2 nd ed. Philadelphia, Lindsay and Blakiston learningradiology.com Balthazar, Emil J. Congenital Positional Anomalies of the Colon: Radiographic Diagnosis and Clinical Implications. Gastrointestinal Radiology. 1977.