An 86-year-old man presented with confusion and right upper quadrant pain. The initial impression was that of acute surgical abdomen but subsequent abdominal x ray showed air below the right diaphragm. The patient was assessed by the surgeons who treated him conservatively and he recovered. Further discussion with the radiology and surgical departments determined this x ray finding to be Chilaiditi sign/syndrome. Chilaiditi sign refers to the asymptomatic interposition of the bowel¹ usually the hepatic flexure of the colon (seen in 0.1–0.25%). It is seen more frequently in adult men and tends to recur. The syndrome can be asymptomatic or may present with abdominal pain, constipation and vomiting. Patients are often managed conservatively.

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Figure 1 Chest x ray of the patient.