Chilaiditi's syndrome masquerading as chest pain
The present case has been reported in the Journal of the Scientific Society. Chilaiditi syndrome is a condition in which the colon or rarely the small bowel is interposed temporarily or permanently between the liver and the diaphragm. Usually it is an asymptomatic and incidental radiographic finding, but may present with a variety of symptoms.

A 72-year-old man who presented with the complaints of chest pain associated with nausea and constipation. On examination, he was hemodynamically stable with normal cardiovascular examination. Bilateral chest was clear on auscultation. His abdomen was distended and nontender, nonrigid, and guarding was absent.

Bowel sounds were normal. Rectal examination revealed hard stools in the rectum. His blood investigations were within the normal limits. Considering his age, initially myocardial infarction was suspected as the cause of his chest pain. Electrocardiogram and cardiac enzymes were done and found to be within the normal limits.

Chest radiograph showed gas under right hemidiaphragm raising the suspicion of perforated bowel. Due to the discrepancy between clinical findings of the abdomen, which were not suggestive of perforation peritonitis and radiological findings, a closer inspection of the X-ray was done.

It showed markings of valvulae connivantes suggestive of small bowel loop interposition between the liver and right hemidiaphragm, which was later confirmed by ultrasound examination.

The patient was managed conservatively by bed rest, antacids, laxatives, and rectal enemas. The patient gradually improved with relief of chest pain, abdominal distension, constipation, and other symptoms. Repeat radiographs showed disappearance of the Chilaiditi's sign. The patient was discharged on the 5 th day and is asymptomatic on follow-up.

Lesson learnt:-
- When confronted with radiographs showing gas under the right hemidiaphragm without signs suggestive of perforation, we should keep this syndrome as differential diagnosis.

- When there is a discrepancy between the clinical features and X-ray findings, greater reliance should be placed on the clinical findings, keeping in mind the age old time honored adage "treat the patient and not the investigations."

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