Case Presentation:
An 18-year-old male patient presented to the emergency department, for
the second time within one week, with recurrent attacks of severe
colicky abdominal pain that was associated with nausea, vomiting, and
constipation. Initially at the first presentation, the pain was vague,
all over the abdomen that was relieved by paracetamol without any
imaging modalities. However, the pain started to progressively increase
in the last 24 hours before the second presentation and became localized
in the right lower quadrant. He had no other relevant symptoms and his
past medical and surgical history was unremarkable.
Upon examination, he looked in pain and had tachycardia of 117 beats/m,
low-grade fever of 37.8°, and a normal blood pressure. He was obese with
body mass index of 31.6 Kg/m2 (82 Kg, 1.61 m). His
abdomen was tender at the right iliac fossa and supra-pubic with rebound
tenderness at the right iliac fossa and audible normal peristalsis. The
rest of the examination was unremarkable. His laboratory investigations
were positive for leukocytosis (13.6 x 106/μL) with
neutrophilia (79.9%), elevated C-reactive protein (25.39 mg/dL) and
elevated erythrocyte sedimentation rate (29). Other laboratory results
including hemoglobin level, renal function, and liver function tests
were unremarkable. He underwent CT of the abdomen with intravenous (IV)
contrast which showed a right-sided intraperitoneal concentric-pattern
mass of fat density with whirling appearance, extending from the
umbilicus to the right iliac fossa that was suggestive of omental
torsion (Figure 1).
Therefore, the patient was admitted for a trial of conservative
management: Nil per os, IV fluids, analgesia, prophylactic IV
antibiotics, and proton pump inhibitors. The antibiotics were
ciprofloxacin and metronidazole to cover gram-negative and anaerobic
bacteria. He was closely observed clinically and, fortunately, his
abdominal pain subsided with non-steroidal anti-inflammatory drugs. He
remained afebrile, with normal vital signs, and his abdominal tenderness
gradually improved. Moreover, his leukocytic count, inflammatory markers
(CRP, ESR) gradually returned to normal levels. Starting from the third
day of admission, he resumed a clear liquid diet which was gradually
escalated to a full diet. His condition showed a good improvement on the
conservative management and he was discharged home, in a good condition,
after seven days. Upon follow-up visit after one, three and six months,
the patient had no symptoms and his clinical examination was
unremarkable.