A 20-year-old male presented to the emergency department complaining of gradually increasing noncolicky pain right side abdomen with multiple episodes of nonprojectile vomiting, obstipation, and progressive abdominal distension for the past 3 days. There was fever with chills and rigor for a similar duration. There was no past history of chronic constipation. There was no personal or family history of tuberculosis. At the time of presentation, the patient was having a pulse rate of 110 beats/minute, a blood pressure of 120/82 mm Hg, and a temperature of 39.5  Celsius. During the abdominal examination, there was tenderness and guarding over the right side of the abdomen with signs of inflammation on the right side back. There was no associated inguinal hernia. On auscultation, bowel sounds were sluggish.
Blood investigations revealed haemoglobin of 11 gm/dL, white cell count of 10,900/cumm with 80% polymorphs, 16% lymphocytes, 2% monocytes, and 2% eosinophil. Liver function test, renal function test, serum electrolyte, serum glucose, and urine analysis were all normal. Typhi antigen card test was negative.
Abdominal X-ray in the erect position showed the right side minimal pleural effusions with dilated loops of the small bowel. Ultrasonography (USG) of the abdomen reported multiple fluid distended intestinal loops suspecting paralytic ileus/subacute intestinal obstruction. The patient was kept on conservative treatment with Ryle's tube suction, intravenous fluids, and parenteral antibiotics. By the 4th day of conservative treatment, the patient started passing flatus and feces and was gradually shifted to a liquid diet.
On the 8th day of admission, the patient complained of painful swelling right scrotum. Scrotal examination showed signs of inflammation with fluctuation on the right side. CT scan of the abdomen showed discontinuity in the posterior wall of ascending colon with a large retroperitoneal collection having multiple internal air lucencies, displacing ascending colon and caecum medically. The right retroperitoneal collection extending superiorly from right pararenal and posterior perihepatic soft tissue planes to the right iliac fossa and right thigh (Figure 1).
Around 350 ml of fecal contents was evacuated by incision & drainage (I&D). The fecal discharge gradually started decreasing while the patient was continued on a liquid diet (Figure 2). The cellulitis of the right side back was also started decreasing. On the 26th day of admission, the patient was discharged in satisfactory condition with no discharge from the scrotal wound. 4-year follow-up was uneventful.