WHEN A WARNING SIGN IS NOT A WARNING SIGN : CHILAIDITI ' S SIGN IN A PATIENT WITH HEART FAILURE AND EPIGASTRIC HERNIA Affiliation

Malposi on of hepa c flexure of colon in sub diaphragma c space, Chilaidi syndrome, is usually an asymptoma c anatomical aberrancy of posi on. It is usually noted as a coincidental finding in chest X-ray. We present a case of 63 years old male who presented as an out-pa ent in the department of general medicine in rural hospital. The pa ent had features of heart failure and also had Chilaidi syndrome as an incidental finding. This case is presented to remind ourselves of a harmless condi on in the myriad of grave condi ons that account for gas under the diaphragm in a chest X-ray.


INTRODUCTION
Gas under diaphragm is an alarming sign that warrants immediate interven on in medical fraternity.Gas under diaphragm is commonly due to hollow viscus perfora on which needs immediate surgical interven on and repair.However, abdominal laparotomy is not required in all cases where free gas under diaphragm is seen in radiology.
Austrian radiologist Demetrius Chilaidi in 1910 reported cases where intes nal loop was posi oned between right 1 sub-diaphragma c space and liver.A er his name this sign is known as Chilaidi sign.The dis nguishing feature of this condi on with other cases of pnemo-peritoneum is absence of agonizing pain.Although this condi on is reported a century ago it is uncommon finding with 2 incidence of 0.025-0.28% in general popula on.This condi on is best treated by conserva ve methods rarely requiring laparotomy.We report such a rare case of Chilaidi sign diagnosed at a rural Hospital in Nepal.The case is more unusual because the pa ent had heart failure and epigastric hernia.

CASE REPORT
A 63 years old male presented to Emergency Room with chief complaint of bilateral pi ng oedema and severe shortness of breath.This dyspnoeic pa ent had respiratory rate of 30 breaths per minute, blood pressure 90/60 mm of Hg, pulse rate 80 beats per minute with normal body temperature.On chest ausculta on, effor ul breathing with bilateral basal crepita on was heard without any murmur.On palpa on, irreducible so lump of 2 x 2 cm was no ced on epigastrium.The mass was associated with posi ve cough impulse which was sugges ve of epigastric    Bhatta SP et al Case Report

DISCUSSION
Radiologically, the 'Dome Sign' which is bilateral dark crescent shadows represen ng the free air under diaphragm is taken as a basic sign of bowel perfora on and 3 pneumo-peritoneum.Perforated bowel is a surgical emergency where the pa ents develop localized agonizing pain which is gradually generalized associated with malaise and vomi ng.The diagnosis of pneumo-peritoneum is solely radiological and 'dome sign' is the commonest in 3 chest X-ray.Other radiological signs to diagnose pneumoperitoneum in supine posi on are 'Rigler's sign', Doge's cap 3-7 sign', Cupola sign', 'Triangle sign' and 'Football sign'.Pneumo-peritoneum is a surgical emergency which warrants for a prompt laparotomy.Failure to diagnose such a case and provide adequate management denotes incompetency in part of the doctor.However, Chilaidi 's sign mimics pneumo-peritoneum, surgery is absolutely not required.
In a view of providing quality health care, the government of Nepal has started to mobilize young medical undergraduates to rural health centres and hospitals.Such hospitals lack modern and advanced imaging techniques like computer tomography and magne c resonance imaging.The rookie doctor has to rely mostly upon the plain radiograph for diagnosis.Interpreta on of radiologic finding is again the duty of the same doctor as most hospitals in rural se ngs have a radiology technician but not a radiologist.Chilaidi 's sign is an incidental finding and not commonly encountered.Many doctors during their undergraduate course might have read about it however, they might not have seen a single case.During prac ce if they happen to encounter such a radiologic finding, there would be a chaos as it is a basic sign of perfora on.In such cases either a pa ent is immediately operated upon or immediately referred to higher centre.These unnecessary opera ons not only possess risk but also generate extra expenses in part of the pa ent.In part of the doctor it is humilia ng and also a ground for li ga on.The best way to differen ate Chilaidi 's sign is not only to depend on the findings upon chest X-ray but to opt for ultra- sonogram to dis nguish it from pneumoperitoneum.Chilaidi 's sign may present with complica ons like abdominal pain, torsion of the bowel or shortness of breath as Chilaidi 's syndrome.In our case the pa ent presented with epigastric hernia.Epigas c hernia in elderly is acquired and usually contains omental fat.The shortness of breath in our case was due to heart failure; however studies suggest 2 that Chilaidi 's sign may be associated with angina.Chilaidi 's sign as an incidental finding is reported from Nepal too which too stresses to evaluate the pa ents for 10 symptoms termed as Chiliadi 's Syndrome.

CONCLUSION
In the present case, the pa ent has visited the health care provider as outpa ent and for shortness of breath rather than for gastrointes nal complaints which made the diagnosis of Chilaidi 's sign easier.When a doctor is posted in an emergency room and finds a Chest x-ray with gas under diaphragm, he is always alerted of emergency.So it is advised to reconfirm the diagnosis by abdominal ultrasonography in any suspicious cases.
hernia.He had no other gastrointes nal symptoms.Rou ne laboratory inves ga ons and basic metabolic panel were within normal limits.Electrocardiogram showed sinus rhythm without any abnormal finding.As per the findings, possibility of heart failure could not be ruled out based on Boston Criteria; and the Fermingham criteria also suggested heart failure as the diagnosis.The doctor was also concerned for the epigastric mass so advised the pa ent for chest X-ray which revealed gas under right dome of diaphragm [Figure 1].This finding made the trea ng doctor suspicious of bowel perfora on.The hospital lacked a d va n c e d ra d i o l o g i ca l i m a g i n g te c h n i q u e s l i ke

Figure 1 :
Figure 1: Chest X-ray in erect posture showing lucency in right subdiaphragma c region.

Figure 3 :
Figure 3: Resolu on of right subdiaphragma c lucency a er 72 hours.