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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 (Figure 1, Figure 2, Figure 3, Figure 4).
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      Figure 1Noncontrast CT of the abdomen (axial view), demonstrating extensive gas in the portal system (arrows).
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      Figure 2Noncontrast CT of the abdomen (axial view), showing gas in the mesenteric venous system (arrowheads) and diffusely dilated loops of bowel with pneumatosis (arrows).
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      Figure 3Noncontrast CT of the abdomen (coronal view), demonstrating gas in the mesenteric venous system (arrowheads) and diffusely dilated loops of bowel with pneumatosis (arrows).
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      Figure 4Noncontrast CT of the abdomen (sagittal view), showing gas in the portal (solid arrows) and mesenteric (arrowheads) venous systems, and diffusely dilated small bowel with pneumatosis (striped arrows).
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