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On the edge of the film…
  1. Helen Williams
  1. Correspondence to Dr Helen Williams, Radiology Department, Birmingham Children's Hospital, Steelhouse Lane, Birmingham, B4 6NH, UK; helen.williams{at}

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From questions on page 15.

ANSWER TO Question 1

The correct answer is E: Chilaiditi's sign, or interposition of bowel between the right hemidiaphragm and the liver. It is usually an incidental finding and is rarely seen in children. However, it is important to recognise because it can be mistaken for pneumoperitoneum. The involved bowel is usually the hepatic flexure of the colon and it may be an intermittent occurrence. It can be associated with anatomical variants such as absence of the falciform ligament or suspensory ligaments of the transverse colon, paralysis or eventration of the right hemidiaphragm, chronic lung disease, cirrhosis and air swallowing. The identification of haustral folds confirms that the air is contained within the bowel, but sometimes computed tomography (CT) may be required for confirmation.

Infrequently, symptoms such as recurrent abdominal pain, distension and respiratory distress are associated with this anatomical variant and accompanying radiological sign; in these cases, it is referred to as Chilaiditi's syndrome. Most cases are managed conservatively, with surgical correction rarely performed.

ANSWER TO Question 2

The correct answer is F: previous BCG vaccination, which has resulted in calcification of lymph nodes in the left axilla. This is a recognised cause of axillary lymph node calcification, and sometimes, symptomatic lymphadenitis.

Axillary lymph node calcification related to BCG vaccination may resolve over months or be persistent. In adult patients, lymph node calcification is more worrying as the differential includes lymph node metastases from breast malignancy or metastatic disease from mucin producing non-breast malignancy, although it is also seen in granulomatous disease and patients receiving gold chrysotherapy (eg, for rheumatoid arthritis).


  • Competing interests None.

  • Provenance and peer review Not commissioned; internally peer reviewed.