DOI: 10.5811/westjem.2014.9.23276

A 76-year-old female with a history of Parkinson’s, dementia, and hypertension presented to the emergency department with non-bilious, non-bloody vomiting and abdominal pain for 2 days. Her exam was significant for borderline hypotension without tachycardia, abdominal distension and a palpable ventral hernia. An emergency physician performed ultrasound showed free intraperitoneal air and gas in the liver (Video). A computed tomography showed pneumoperitoneum, pneumatosis intestinalis, and hepatic portal venous gas (HPVG) (Figure). At laparotomy, she was found to have a sigmoid colon perforation from adenocarcinoma, ischemic small bowel, and a colovesicular fistula. Post-operatively her clinical status worsened, and she was transitioned to comfort care and expired on hospital day 2. HPVG was first reported in infants with necrotizing enterocolitis.1 In adults, it is most commonly associated with mesenteric ischemia and pneumatosis intestinalis, accounting for 43 % of HPGV cases2 and an associated mortality o