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Clinical Images

Free Air?

Sourabh Aggarwal, MBBS, Mark Loehrke

August 5, 2016

An 86-year old female presented with nausea, non-bilious vomiting, diarrhea, abdominal pain, and dysuria for 3 days. Her past medical history was significant for hypertension, congestive heart failure, chronic obstructive pulmonary disease, and a coronary artery bypass graft. Her husband was recently treated for Clostridium difficile-associated diarrhea. On examination, she was afebrile, showed evidence of intravascular volume depletion, had bibasilar rales, and exhibited abdominal distention without tenderness, guarding, or rigidity. Initial labs revealed leukocytosis, pyuria, bacteriuria, and stool positive for occult blood. Clostridium difficile toxin by polymerase chain reaction returned positive. Blood cultures were unremarkable. Chest X-ray showed a sub-diaphragmatic air shadow (Figure 1), which was a new finding compared to previous imaging. CT scan of the abdomen was ordered (Figure 2).

CT revealed a distended colon in the sub-diaphragmatic area with diffuse circumferential wall thickening, consistent with pseudo-pneumoperitoneum and a diagnosis of Chilaiditi syndrome. She was admitted to the intensive care unit and started on intravenous fluid resuscitation, vasopressor support with norepinephrine drip, intravenous metronidazole, and oral vancomycin. Her hospitalization was complicated by cholecystitis with cholelithiasis, for which a percutaneous cholecystostomy tube was placed, as well as a non-ST elevated myocardial infarction. Her clinical status deteriorated gradually with increasing vasopressor requirements. The family decided to withdraw care, and the patient ultimately expired.



A 35-year old patient presents to the emergency department with complaints of abdominal distention and right upper quadrant abdominal pain. Chest X-ray reveals an air shadow below the diaphragm. 


1. Farkas R, et al. Chilaiditi’s sign in a blunt trauma patient: a case report and review of the literature. J Trauma. 2008;65:1540-2
2. Moaven O, Hodin RA. Chilaiditi syndrome: a rare entity with important differential diagnoses. Gastroenterol Hepatol (N Y). 2012;8:276-8


1. Sourabh Aggarwal, MBBS, Cardiology Fellow, Department of Cardiology, University of Nebraska Medical Center, Omaha, Nebraska. 
2. Mark Loehrke, Associate Professor and Chair, Program Director, Department of Internal Medicine, Western Michigan University School of Medicine, Kalamazoo, Michigan