Anaesthesia management of a patient with Chilaiditi syndrome: perioperative mechanical ventilation challenges

Chilaiditi syndrome is a rare condition, reported in 0.025%-0.28% of the population, in which bowel interposition between the liver and the right hemidiaphragm becomes symptomatic. A male patient in his 60s with hypertension, hypothyroidism, ischaemic cardiomyopathy, chronic kidney disease and a 40-pack-year smoking history presented with progressive abdominal distension, nausea and vomiting for 3 days. He underwent urgent laparotomy with repair of a proximal jejunal perforation. After tracheal intubation, peak airway pressure increased to 50 cmH2O. Lung-protective ventilation with low tidal volumes, permissive hypercapnia, head-up positioning and nasogastric decompression improved compliance and reduced airway pressures to 36 cmH₂O. In the intensive care unit (ICU), staged ventilatory adjustments facilitated gradual weaning to bilevel positive airway pressure (BiPAP) by postoperative day 3. This case shows how Chilaiditi syndrome, complicated by bowel obstruction, can impair respiratory mechanics and create major intraoperative ventilatory challenges. Careful airway pressure interpretation and planned postoperative ventilatory support were central to safe management.