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 Table of Contents  
CASE REPORT
Year : 2018  |  Volume : 4  |  Issue : 2  |  Page : 53-54

Colostomy in A Case of Anorectal Malformation Presenting as Chilaiditi Syndrome


1 Additional Professor, Department of Pediatric Surgery, IGIMS, Patna, India
2 Professor, Department of Pediatric Surgery, IGIMS, Patna, India
3 Assistant Professor, Department of Pediatric Surgery, IGIMS, Patna, India

Date of Web Publication10-Dec-2020

Correspondence Address:
Zaheer Hasan
Additional Professor, Dept. of Pediatric Surgery, IGIMS, Patna, Bihar
India
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Source of Support: None, Conflict of Interest: None


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  Abstract 


Chilaiditi syndrome is the interposition of the right colon between the liver and the right hemi diaphragm. Generally, the patients are asymptomatic but can present symptoms mimicking intestinal obstruction. Although, there are many complications related to colostomy in the patients of anorectal malformation, appearance of Chilaiditi syndrome is unusual Further, hypokalemia can be a precipitating factor for the development of Chilaiditi syndrome.

Keywords: Anorectal malformation, Chilaiditi syndrome, Hypokalemia, Stenosed colostomy


How to cite this article:
Hasan Z, Thakur VK, Kumar V, Yadav R, Rahul SK, Chaubey D. Colostomy in A Case of Anorectal Malformation Presenting as Chilaiditi Syndrome. J Indira Gandhi Inst Med Sci 2018;4:53-4

How to cite this URL:
Hasan Z, Thakur VK, Kumar V, Yadav R, Rahul SK, Chaubey D. Colostomy in A Case of Anorectal Malformation Presenting as Chilaiditi Syndrome. J Indira Gandhi Inst Med Sci [serial online] 2018 [cited 2021 Dec 4];4:53-4. Available from: http://www.jigims.co.in/text.asp?2018/4/2/53/302958




  Introduction: Top


Anorectal malformation is a congenital malformation in which colostomy is commonly performed. Incorrectly performed colostomy can cause complications. One of them is Chilaiditi's syndrome. It is commonly observed in elderly population and presents as an asymptomatic X-Ray finding (Chilaiditi's sign), but may be associated with intestinal obstruction. We report a case of Chilaiditi syndrome in a case of anorectal malformation with colostomy in situ.


  Case Report: Top


A three year old boy presented to the emergency with history of recurrent pain in the abdomen and huge abdominal distension for one month. Patient was a case of anorectal malformation with divided sigmoid colostomy done at birth and posterior sagittal anorectoplasty done subsequently. Patient was waiting for the colostomy closure. Meanwhile, the patient developed features of acute abdominal obstruction. Patient was also passing foul stool. Hemogram and kidney fuction test were within normal limits. Serum electrolyte showed reduced level of potassium (2.4 meq/dl). Plain X-ray of abdomen and pelvis showed multiple air fluid level with abnormal gas shadow between the right dome of diaphragm and liver [Figure 1] simulating intestinal perforation but on the careful analysis, it was found to be shadow of transverse colon that was pushed between the right dome of diaphragm and liver. Ultrasonography of the abdomen showed distended bowel loops. Patient was given intra venous fluid with potassium supplementation. Nasogastric tube was placed. During the surgery whole of the large gut was found to be distended proximal to stenosed colostomy along hypermobile and redundant transverse colon [Figure 2]. End to end anastomosis between the descending colon and rectum was performed together with colopexy. Post-operative period was uneventful. Patient was asymptomatic in the follow up visit and was advised anal dilatation protocol.
Figure 1: Photograph showing colonic superimposition under right dome of diaphragm

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Figure 2: Intra- operative photograph showing dilated colon

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  Discusssion: Top


Chilaiditi syndrome is usually asymptomatic and rare clinical condition. Chilaiditi syndrome is most commonly seen in the elderly with a incidence of 1%, but there have been cases where it was presented in the neonate[1]. Its main features are abdominal distension and pain with X-ray finding of colon between liver and diaphragm. Liver, diaphragm and intestine are involved in causation of Chilaiditi syndrome[2]. The atrophic or small liver, post necrotic sudden liver shrinking, relaxation of suspensor ligaments are the various hepatic factors involved[3]. Absence of peritoneal attachments and redundant colon with a long mesentery, abnormal colonic motility, dilated colon and Colonic elongation are the principal predisposing intestinal factors[4]. A possible diaphragmatic factor is the abnormal position of diaphragm due to muscular degeneration caused by phrenic nerve injury[4]. Although, it is usually asymptomatic there are many atypical presentations reported in the literature. Chilaiditi syndrome is mainly differentiated with volvulus, intussusception, ischemic bowel, or inflammatory conditions and diaphragmatic hernia[5]. However, colonic pseudo-obstruction (Ogilvie syndrome) has also been observed in patients with Chilaiditi syndrome[6]. Once Chilaiditi syndrome is diagnosed, it is managed conservatively. However, if there are signs of increased obstruction or there is development of signs of peritonism, then surgical intervention may have to be done[7]. The association of Chiladaiti syndrome in a patient of anorectal malformation with colostomy is unusual. In their study Patwardhan et, al reported mechanical complication associated with colostomy in sixteen patients.

These are mainly adhesion, volvulus and intussusception[8]. In our case proximal divided sigmoid colostomy was stenosed causing dilatation of entire large gut and transverse colon got stuck between right diaphragm and liver. It was because divided stoma was too much close to each other causing stenosis to the proximal stoma. Dilatation of colon was further accentuated by hypokalemia associated with colostomy and the subsequent development of Chilaiditi syndrome.

So, hypokalemia can be a precipitating factor along with stenosed colostomy leading to development of Chilaiditi syndrome in a case of anorectal malformation.



 
  References Top

1.
Rajdhar Dutt and Chandrakala Dutt. Chilaiditi Syndrome: A Rare Manifestation in Newborn. Journal of clinical neonatology. 2013 ; 2(1): 50-1.  Back to cited text no. 1
    
2.
Kolju KJ. Roentgendiagnosis of hepatodiaphragmatic interposition of large intestine.AJR1938;39;928-36.  Back to cited text no. 2
    
3.
Chan SC, Liu CL, Lo CM, Fan ST. Rapid onset Chilaiditi's sign on top of fulminant hepatic failure. Hepatobiliary. Pancreat Dis Int.2004;3(3):476-7  Back to cited text no. 3
    
4.
Saber AA, Boros MJ. Chilaiditi's syndrome:what should every surgeon know? Am Surg. 2005;71(3):261-3  Back to cited text no. 4
    
5.
Altomare DF, Rinaldi M, Petrolino M, et al. Chilaiditi's syndrome. Successful surgical correction by colopexy. Tech Coloproctol. 2001;5:173-5.  Back to cited text no. 5
    
6.
Plorde JJ, Raker EJ. Transverse colon volvulus and associated Chilaiditi's syndrome: case report and literature review. Am J Gastroenterol.1996;91:2613-6.  Back to cited text no. 6
    
7.
Rachid Guimarães Nagem, Henrique Leite Freitas. Chilaiditi's syndrome: a case report. Radiol Bras. 2011;44(5):333-335.  Back to cited text no. 7
    
8.
Demirba? S, Kurt Y, Akin M, Oztürk A, Celenk T. Chilaiditi's syndrome with pancreatic malignancy. Turkish J Cancer. 2007;37(3):117-9.  Back to cited text no. 8
    
9.
Matthews J, Beck GW, Bowley DM, et a. Chilaiditi's syndrome and recurrent colonic volvulus: a case report. J R Nav Med Serv.2001;87:111-2.  Back to cited text no. 9
    
10.
Chen SY, Liu CT, Tsai YC, Yu JC, Lin CH. Sigmoid volvulus and associated Chilaiditi's syndrome. Rev Esp Enferm Dig.2007;99(8):482-3.  Back to cited text no. 10
    
11.
Murphy JM, Maibaum A, Alexander G, et al. Chilaiditi's syndrome and obesity. Clin Anat.2000;13:181-4.  Back to cited text no. 11
    
12.
N. Patwardhan,E.M Kiely,D.P Drake,L Spitz,A Pierro. Colostomy for anorectal anomalies: High incidence of complications. Journal of Pediatric surgery.2001; 36:795-8.  Back to cited text no. 12
    


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