Hemi-diaphragmatic interposition of the colon is clinical entity and its incidence about 0.25% to 0.28% of the general population [1]. It was first described by Demetrious Chilaiditi in 1910 [5]. He described this phenomenon of movement of the liver that allows the transverse colon to interpose between it and the hemidiaphragm on abdominal roentgenology [5]. Demetrious Chilaiditi, original 3 cases presented with intermittent abdominal pain that resolved without surgery. The sign is usually not associated with symptoms. Chilaiditi's syndrome is a clinical abnormality consisting of episodic, recurrent, abdominal pain sometimes associated with colonic volvulus but occasionally with intermittent upper abdominal pain.

Usually there is abnormal anatomy of colon. Hepatic flexor is with loose mesentery and due to this, lax transverse colon get displaced between right lobe of liver and right hemi diaphragm. Sometime, due to lax transverse mesocolon, the transverse colon shift anteriorly and medially in the subhepatic space (Morison's pouch) and thus crosses  beneath the proximal duodenum and extending anterior to the pancreatic head and may press the anterior surface of the duodenal-jejunal flexure resulting in obstruction [6].

The radiologic anatomy of the patient's colon is usually atypical in Chilaiditi's syndrome and it may show movement of abnormal one-half the length of the transverse colon into the subhepatic space and Winslow's canal [5,8]. The exact cause is not always known, but it may occur in patients with a long and mobile colon (dolichocolon), chronic lung disease such as emphysema, or liver problems such as cirrhosis and ascites. Chilaiditi's sign is generally not associated with symptoms, and is most commonly an incidental finding in normal individuals. Absence or laxity of the ligament suspending the transverse colon or of the falciform ligament are also thought to contribute to the condition. It can also be associated with relative atrophy of the medial segment of the left lobe of the liver. In this case, the gallbladder position is often anomalous as well – it is often located anterior to the liver, rather than posterior

Normally this causes no symptoms, and this is called Chilaiditi's sign. The sign can be permanently present, or sporadically. This anatomical variant is sometimes mistaken for the more serious condition of having air under the diaphragm (pneumoperitoneum) which is usually an indication of bowel perforation, possibly leading to surgical interventions. Chilaiditi syndrome refers only to complications in the presence of Chilaiditi's sign. These include abdominal pain [9], torsion of the bowel transverse colon volvulus [10,11] or shortness of breath [4].

Differential diagnosis includes interpositio hepato-diaphragmatica, subphrenic displacement of the colon, subphrenic interposition syndrome and pseudo pneumoperitoneum. Since laparoscopic treatment has been successful with colonic malformations [12,13], So,  diagnostic laparoscopic is essential to rule out  possible serious colonic etiologies. Conservative management is gold standard and surgical intervention is required when there is associated colonic malformations or to relieve the obstruction or for management of frequent respiratory distress.