A 64-year-old man with a history of lung cancer (treated with lobectomy and chemotherapy with cisplatin and etoposide, 3 months before) was examined in our emergency department suffering from diffuse abdominal pain starting 6 days previously. The patient presented with abdominal fullness and constipation lasting for 3 days.
Physical examination revealed rebound tenderness and heart rate 100 bpm. Laboratory exams showed: WBC, 1100 cells/mm3 (NEUT = 44%); HCT, 32%; CRP, 360 mg/dL; K, 5.9 mEq/L; Na, 132 mEq/L; PLT, 69,000; Tbil, 2.90 mg/dL; Dbil, 1.90 mg/dL; CPK, 2530 U/L; LDH, 670; Na, 132 mEq/L; K, 5.9 mEq/L; SGOT, 180; SGPT, 183.
Abdominal X-ray did not demonstrate subdiaphragmatic free intra-abdominal air.
Emergency abdominal CT showed air in the hepatic portal veins (Fig. 1), focal dilatation of the small bowel with wall thickening, mesenteric fat stranding and peritoneal fluid collection, free air in the retroperitoneum, mainly to the right (retroperitoneum) (Fig. 2), air in the peritoneal cavity, mainly in the lower pelvic area, and free air in the pararectal space (Fig. 3). Air was also demonstrated in both inguinal canals mainly in the right and in both iliac-femoral veins (Fig. 4). Moreover, pleural effusion and atelectasis was found in both lower lobes of the lungs (Fig. 1).     
Laparotomy revealed extensive colon and small bowel necrosis distal to the jejunum. The affected region, ileum, and right colon up to the mid-transverse part, was resected, and an ileostomy and a transverse colostomy was made. The patient died after few hours in the intensive care unit from multiple organ failure.
Histology examination revealed transmural colonic and small bowel necrosis with evidence of active thromboembolic process and leucocytoclastic vasculitis.