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.