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.