Chilaiditi Sign: Rare Incidental Finding on Chest Radiograph

Author Affiliation
Krystal Garcia, BS Edward Via College of Osteopathic Medicine, Carolinas Campus, Spartansburg, South Carolina
John Ashurst, DO, MSc Duke Lifepoint Memorial Medical Center, Department of Emergency Medicine, Johnstown, Pennsylvania



Chilaiditi sign, also called pseudopneumoperitoneum, is named after the Greek radiologist, Dmitri Chilaiditi, who first described it in 1910.1 It is an interposition of bowels between the liver and right diaphragm and appears as free air on chest radiograph.2,3 This sign is found in <0.3% of the population with highest incidence in elderly males.2 To diagnosis Chilaiditi sign, the following criteria must be met: (1) right hemidiaphragm must be elevated above liver by intestine, (2) bowel must be distended by air, (3) and the superior margin of the liver must be depressed below the level of the left hemidiaphragm.

If symptomatic, this is referred to as Chilaiditi syndrome, which can manifest as abdominal or cardiac symptoms with self-resolution or chronicity.1,2 Usually only conservative treatment is required for patients with Chilaiditi syndrome, but surgery may be needed for severe cases.1 The emergency physician should be aware of this condition as a potential mimicker of intraperitoneal free air on chest radiograph.


Section Editor: Sean O. Henderson, MD

Full text available through open access at

Address for Correspondence: John Ashurst, DO, MSc, Duke Lifepoint Memorial Medical Center, Department of Emergency Medicine, Johnstown, PA 15905. Email: 12 / 2015; 16:1206 – 1207

Submission history: Revision received September 13, 2015; Submitted September 21, 2015; Accepted October 1, 2015

Conflicts of Interest: By the WestJEM article submission agreement, all authors are required to disclose all affiliations, funding sources and financial or management relationships that could be perceived as potential sources of bias. The authors disclosed none.


1. Lekkas CN, Lentino W. Symptom-producing interposition of the colon. Clinical syndrome in mentally deficient adults. JAMA. 1978;240(8):747-50.

2. Jangouk P, Zaidi F, Hashash JG. Chilaiditi’s Sign: A Rare Cause of Abdominal Pain. ACG Case Rep J. 2013;1(2):70-1.

3. Kang D, Pan AS, Lopez MA, et al. Acute Abdominal Pain Secondary to Chilaiditi Syndrome. Case Rep Surg. 2013;2013:756590.

Upright chest radiograph demonstrating Chilaiditi sign (pseudopneumoperitoneum) mimicking apparent free intraperitoneal air under the right hemidiaphragm.