A 65-year-old male presented with features suggestive of an obstructed right inguinal hernia. An X-ray of the abdomen in the standing position was suggestive of free gas under the right hemidiaphragm (Figure 1). Classical haustral markings could be seen, however, which led to the suspicion of Chilaiditi’s anomaly. Normal loops of bowel were seen on inguinal surgery and herniorrhaphy was performed. The patient was counselled about the incidentally discovered anomaly.

Chilaiditi’s Syndrome (CS) is a hepatodiaphragmatic interposition of the colon and rarely the small intestine. It occurs in increased proportions in patients with chronic lung disease, post necrotic cirrhosis, and ascites. Colonic elongation and laxity of colonic and hepatic suspensory ligaments are the principal predisposing factors.

Although it is usually asymptomatic and an incidental finding in the elderly population, several atypical presentations have been reported in the literature in the form of isolated case reports—and include abdominal discomfort, constipation, partial obstruction, nocturnal vomiting, and recurrent volvulus involving transverse colon and both flexures. In symptomatic cases, suggested treatment options include transverse colectomy, right hemicolectomy, and hepatic extraperitonealisation (hepatopexy).

Although classical haustral markings suggestive of the diagnosis may sometimes be seen, the presence of overlapping features frequently leads to a dilemma in diagnosis. A strong clinical suspicion is advocated to prevent an unnecessary laparotomy. In the elderly especially, this should always be considered in the differential diagnosis for free gas under the dome of the right hemidiaphragm.