A 60-year-old man was admitted to the emergency room of Beijing Hospital in the afternoon of March 8, 2016 with severe epigastric dilation, stomachache and fever. He had localized epigastric pain for 2 days before being admitted without fever. In the morning before admission, he began vomiting, and the abdominal pain spread to the entire stomach along with a high fever of 39.5 C. Two weeks earlier, he received an endoscopic biliary stenting operation due to obstructive jaundice caused by unresectable pancreatic cancer. The serum total bilirubin (TBIL) decreased from 160.7 mumol/L before the procedure to 46.2 mumol/L at discharge, and the direct bilirubin (DBIL) decreased from 124 mumol/L to 37.9 mumol/L. Nothing uncomfortable happened until the onset of abdominal pain. In physical examination, his blood pressure was 95/65 mmHg, his pulse 110 bpm. The abdominal examination showed abdominal distention, hepatomegaly with a liver span of 2 cm below the right costal margin, epigastric tenderness with mild rebounding pain, and almost no gurgling sound.
According to the history of pancreatic cancer and endoscopic intervention, we first excluded several common conditions, such as pancreatitis, cholangiolitis, especially retrograde type after stenting, and some stent-related problems, such as stent dislocation and stent reobstruction. Therefore, relevant blood tests and cultures and abdominal CT scans were administered immediately.
Laboratory data and changes are shown in Tables 1-3. The emergency abdominal CT scan shown in Figure 1 with comparison with past radiologic materials revealed irregular gas-containing lesions in the liver, containing liver parenchymal moth-eaten destruction and a pneumatized bile duct without obvious inflammation around, and the stent was right in the common bile duct without obstruction. It could be deduced that the gas came retrogradely from the duodenum because of the damage to Voter's ampulla or was generated by several kinds of special bacterial infection. The infection originated from the intrahepatic duct and deteriorated with adjacent parenchymal damage, and all the aerated lumens communicated with the bile ducts.   
According to the parameters, we diagnosed the patient with severe intrahepatic infection caused by enterogenous aerogenes, multiorgan deficiency involving hepatic, renal, and cardiac injuries and coagulopathy. We treated him with a board-spectrum antibiotic (biapenem 0.3 g Q12H and ornidazole 100 mg Q12H intravenously) and vigorous fluid resuscitation under intensive care. Ten hours after hospitalization, his blood pressure began falling, and inotropic support was started with intravenous infusion of norepinephrine. Nevertheless, his clinical condition deteriorated with multiorgan failure. Finally, he succumbed at the 20th hour of hospitalization to sudden cardiac arrest.
The method of blood specimen culture was as follows: the blood sample was taken aseptically, injected into culture bottles (BacT/ALERT  SA and SN, BioMerieux Company, Lyon, France) immediately, and put into the BacT/ALERT automated blood culture system. Twenty-four hours later, the BacT/ALERT SN bottle was positive for alarm, and gram-positive bacilli were seen on direct smears. The bacilli were transferred to a Colombian medium blood plate and cultivated in both aerobic and anaerobic environments at 37 C. Twenty-four hours later, gray-white, round, serrated colonies with double-hemolytic rings were seen on the plate in the anaerobic environment. Finally, the blood culture results revealed a Clostridium perfringens infection according to an automatic bacterial identification system (Vitek 2 COMPACT, BioMerieux Company, Lyon, France).