A 44 year old man previously in good health presented to the accident and emergency department with a 3-day history of gradually worsening abdominal pain. The pain started as a dull ache in the periumbilical region and later became diffuse and more severe. He developed diarrhoea 24 hours after the pain started, opening his bowels up to 10 times a day. This was initially brown watery motion but later became mixed with dark blood. There was associated vomiting and anuria.

On examination he was mildly jaundiced and dehydrated. His temperature was 39°C. His pulse was irregular at a rate of 120 beats/min, blood pressure 95/40 mm Hg. His abdomen was distended and diffusely tender, rectal examination was unremarkable. Initial investigations showed a haemoglobin of 17.9 g/dl, white cell count 24 ×10⁹/l, urea 22 μmol/l, creatinine 200 μmol/l, bilirubin 29 μmol/l and alkaline phosphatase 308 IU/l; urinalysis, electrolytes and amylase were otherwise normal. Blood gases showed a mild metabolic acidosis and electrocardiogram confirmed the presence of atrial fibrillation. Chest x-ray was normal; abdominal x-ray is shown in fig1.

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Figure 1

Abdominal x-ray.