doi:10.1016/j.jemermed.2009.02.008 Visual Diagnosis in Emergency Medicine PNEUMATOSIS INTESTINALIS AND GAS IN PORTAL VEIN ASSOCIATED WITH SMALL BOWEL OBSTRUCTION Amer A. Alkhatib, MD,* Fateh A. Elkhatib, MD,* Omar F. Alkhatib, MD,† and Robert Zurcher, MD‡ *Division of Hospitalist, Department of Internal Medicine, Holy Family Hospital, Spokane, Washington, †Department of Internal Medicine, Cleveland Clinic Foundation, Cleveland, Ohio, and ‡Department of Emergency Medicine, Holy Family Hospital, Spokane, Washington Reprint Address: Amer Alkhatib, MD, Division of Hospitalist, Department of Internal Medicine, Holy Family Hospital, 5633 N. Lidgerwood St., Spokane, WA 99208 CASE REPORT A 60-year-old man with a history of hypertension, em- physema, and coronary artery disease presented to the Emergency Department with a 5-day history of abdom- inal pain, nausea, vomiting, and melena. The patient had had multiple abdominal surgeries in the past, including cholecystectomy and appendectomy. On examination, the patient was hypothermic (35°C [95°F]) and hypoten- sive (blood pressure 62/40 mm Hg). He had a distended tympanic abdomen without tenderness. His bowel sounds were hypoactive. His laboratory studies were significant for acute renal failure (creatinine 3.4 mg/dL) and leuko- cytosis (white blood cell count 29,200 cells/L). Upright abdominal plain radiographic imaging showed multiple markedly distended loops of small intestine throughout the abdomen, measuring up to 6 cm. Supine abdominal plain radiographic imaging showed dilatated intestine and pneumatosis intestinalis (Figure 1). The computed tomography (CT) scan with oral contrast confirmed pneumatosis intestinalis (Figure 2) and showed gas in the portal venous system (Figure 3). The CT images were consistent with small bowel obstruction secondary to internal hernia or adhesion. Based on the imaging studies and the patient’s clinical status, the decision was made to take the patient to the operating room. Within 3 h after obtaining the imaging studies and before surgical intervention, the patient de- veloped severe hypoxemia, bradycardia, and hypoten- sion. He died within a few hours of presentation. RECEIVED: 6 October 2008; FINAL SUBMISSION RECEIVED: 4 January 2009; ACCEPTED: 6 February 2009 Figure 1. Supine plain radiograph of the abdomen show- ing pneumatosis intestinalis (arrow) and dilatated small intestine. The Journal of Emergency Medicine, Vol. 40, No. 6, pp. e125– e126, 2011 Copyright © 2011 Elsevier Inc. Printed in the USA. All rights reserved 0736-4679/$–see front matter e125