Man With Abdominal Pain and Bilious Emesis

A 62-year-old man with diabetes, chronic kidney disease, and atrial fibrillation presented to our emergency department with sudden-onset abdominal pain and bilious emesis. Initial vital signs showed a blood pressure of 90/60 mm Hg, pulse rate of 135 beats/min, and tympanic membrane temperature of 36.8°C (98.2°F). Physical examination was notable for a distended abdomen with rebound tenderness and hypoactive bowel sounds. Initial laboratory testing result was notable for leukocytosis. Noncontrast enhanced abdominal computed tomography (CT) showed extensive gas in the mesenteric and hepatic portal venous system, and small bowel dilatation with pneumatosis (Figures 1 to 4).

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