A 45-year-old man presented to the emergency room with abdominal pain that had been increasing over the previous week and hematemesis and melena that had begun in the preceding 12 hours. He had drunk 36 alcoholic drinks per day for 20 years and had been on a binge for the 2 days preceding his admission. On presentation, he was in clinical shock, with an unrecordable blood pressure and a heart rate of 117 beats per minute. He had acidosis (blood pH, 7.27), coagulopathy (international normalized ratio, 1.3), and acute renal failure (ratio of blood urea nitrogen [millimoles per liter] to creatinine [micromoles per liter], 0.05; estimated glomerular filtration rate, 19 ml per minute per 1.73 m2 of body-surface area). He underwent fluid resuscitation and was given packed red cells, fresh-frozen plasma, vitamin K, and a proton-pump inhibitor. Computed tomography of the abdomen and pelvis was performed to investigate signs of peritonitis, and the studies showed extensive gas in the portal venous system (Panel A, arrowheads) and the superior mesenteric vein (Panel B, arrowhead). The bowel was necrotic, with gas in the wall (Panel B, arrows). His serum lactate level was 8.6 mmol per liter. The patient died 6 hours after presentation.
Cheng and Pande NEJM 361 (20): 1979, Figure 1 November 12, 2009