P0158 - A Curious Case of Chronic Intestinal Pseudo-Obstruction

Rafaela Izurieta, MD, Howard Lee, MD, Kimberly Zibert, DO
San Antonio Uniformed Services Health Education Consortium, Fort Sam Houston, TX

Introduction: Chronic intestinal pseudo-obstruction (CIPO) presents as recurrent clinical symptoms of bowel obstruction without an identifiable transition point. It is a diagnosis of exclusion after ruling out congenital and acquired mechanical or motility disorders. We present a case of Chilaiditi syndrome masquerading as CIPO.

Case Description/Methods: An 18 year old man presents for the fourth time in one month with symptoms of abdominal distension, bloating, early satiety and nausea. On each admission, imaging demonstrates colonic dilation up to 17cm without mechanical obstruction or transition point. Rectal biopsies, anal rectal manometry and SmartPill excluded organic motility or neuropathic disorders and serologies were negative for infectious and inflammatory etiologies. Our patient was treated for CIPO by urgent gastric and rectal decompression, prokinectic agents, and secretagogues, with temporary relief. However, at the fourth admission, endoscopic concern of volvulus during decompression prompted CT with barium enema which was consistent with Chilaiditi syndrome: a medially-displaced liver with a portion of colon over the dome of liver. Surgical interventions were discussed in the setting of repeated admissions, and he underwent right and transverse colectomy with primary anastomosis.

Discussion: Chilaiditi sign is an asymptomatic interposition of bowel between the liver and right hemidiaphragm. It has an incidence of 0.025-0.28%. Chilaiditi syndrome is defined by these radiologic findings with accompanying symptoms. Possible etiologies are extensive, including variations in suspensory ligaments of the colon or falciform ligament, congenital malformations, colonic redundancy, ascites, small liver and hepatectomy. Diagnosis should exclude other treatable or life-threatening conditions.

In asymptomatic patients, no intervention is necessary. Those with abdominal distension or pain may benefit from pain control and fluid resuscitation. In patients with evidence of bowel ischemia or recurrent presentations, surgical intervention should be offered. In our patient, the decision was made to proceed with surgical intervention after exclusion of other etiologies and when endoscopy and CT imaging was found to be consistent with Chilaiditi syndrome, but no long-term relief was achieved with multiple decompressions and conservative measures. The etiology of Chilaiditi Syndrome is varied. In this case, it may have occurred secondary to redundancy of the right and transverse colon noted intraoperatively.


Figure: A. CT abdomen/pelvis without contrast demonstrating a diffusely dilated, air-filled gastrointestinal tract extending from the stomach through the rectosigmoid colon. No transition point or obstruction noted.
B. CT abdomen/pelvis with rectal contrast demonstrating an interposition of the hepatic flexure of the colon posterior and medial to the right lobe of the liver. No evidence of obstruction or strangulation noted.
C. Endoscopy demonstrating a twisted, almost volvulus-like appearance at the splenic flexure, though without clear transition points.


Disclosures:
Rafaela Izurieta indicated no relevant financial relationships.
Howard Lee indicated no relevant financial relationships.
Kimberly Zibert indicated no relevant financial relationships.


Rafaela Izurieta, MD, Howard Lee, MD, Kimberly Zibert, DO. P0158 - A Curious Case of Chronic Intestinal Pseudo-Obstruction, ACG 2021 Annual Scientific Meeting Abstracts. Las Vegas, Nevada: American College of Gastroenterology.