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Case of the Month 2/08

This 84 year old female was sent to the ED by her PMD after the doctor noticed a positive urine dip and lower abdominal tenderness on exam in the office. The patient had been diagnosed with a UTI 10 days earlier and had completed a course of PO levofloxacin. Q: What’s wrong with this picture? What are the possible explanations for such a finding?

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There is a lucency below the right diaphgram. This could be free air from viscus perforation, an air fluid level due to an abscess or colonic interposition (also known as Chilaiditi syndrome).

Q: What are some options for further elucidating the cause of this finding?

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Possible options include a lateral CXR, a left lateral decubitus CXR and/or an abdominal CT. In this case, the patient had all three types of imaging done which revealed the finding to be due to colonic interposition of the colon. Note the haustral markings (arrows) on the plain films and the contrast filled intestine anterior to the liver on the abdominal CT below. Colonic interposition is a common variant in which the colon moves to a position between the liver and the right hemidiaphgram. It does not require treatment.