Case History/Examination
A 20 year-old Caucasian male with a past medical history of lactose
intolerance and COVID-19 presented with over a year of ongoing abdominal
pain and distention. The patient had military training history but no
contributing travel or family history. In the Fall of 2021, the patient
underwent an exploratory laparoscopy after presenting with abdominal
distension and a computerized tomography (CT) scan suggestive of
pneumoperitoneum and free abdominal fluid. During this first exploratory
laparoscopy, congenital malrotation was identified as the cecum was in
the right upper quadrant, and was corrected by Ladd’s procedure with
adhesiolysis. During surgery, the mid-section of the ileum appeared
inflamed. At that juncture, there was no clear etiology for the free air
in the peritoneum. Ascitic fluid cell analysis and peritoneal lymph node
biopsy were negative for malignancy. Lymph node biopsy showed
mesothelial-lined fibrovascular tissue with chronic reactive and
inflammatory changes. He was discharged after tolerating an advancing
diet.
In the winter of 2021, he noticed a return of intermittent abdominal
bloating and discomfort, decreased appetite, along with generalized
weakness and weight loss. He reported intermittent distention, where for
24-48 hours, he would experience abdominal distension with spontaneous
resolution without passage of gas. He then underwent colonoscopy and
esophagogastroduodenoscopy (EGD), which were unremarkable.
His chronic symptoms of mild abdominal pain and distention acutely
worsened 2-3 weeks before presenting to our emergency department (ED) in
the Fall of 2022. His lower abdominal pain worsened and spread to the
right upper quadrant without relief from simethicone or dicycloverine.
Upon presenting to ED, his vital signs were stable and moderate
abdominal distension was appreciated on physical exam. There were no
focal peritoneal signs.