Chilaiditi syndrome mimicking pneumoperitoneum

A 96-year-old woman with dementia and total dependency on activities of daily living (ADL) presented to the emergency department (ED) due to tachypnea and a large amount of sputum production. Two days before her presentation to the ED, she experienced a choking episode. She also had poor appetite and constipation recently. Upon physical examination, the patient had a body temperature of 36.5 °C, pulse of 118 beats per minute, respiratory rate of 20 breaths per minute, blood pressure of 162/102 mmHg, and low oxygen saturation (SpO2: 89% without oxygen support). Crackle was heard over bilateral lung fields. Her abdomen was soft and without tenderness, but tympanic on percussion. Laboratory data was as follows: white blood cell count 7900 cells/micro-L with 92.2% segmented neutrophils; glucose, 187 mg/dL; amylase, 57 U/L; procalcitonin, 0.24 ng/ml; and lactate level, 31.4 mg/dL. Chest radiograph showed bilateral ground-glass opacity in the bilateral lungs and a radiolucent area over the right subphrenic space (Fig. 1A). Right subphrenic radiolucency on the chest radiograph was noted. Computed tomography of the abdomen was performed and revealed interposed colonic loops between the diaphragm and the liver without intra-abdominal free air (Fig. 1B). The image indicated Chilaiditi syndrome. Due to the presentation of poor appetite and ileus, conservative treatment with the prokinetic agent was given for colonic ileus. Furthermore, the patient was admitted to the medical ward for further treatment for aspiration pneumonia. Unfortunately, she died of pneumonic desaturation after the decision of do not resuscitate by her family 34 h later. The major cause of fatality was septic desaturation rather than Chilaiditi syndrome.