An 82-year-old woman presented to the emergency department with pain in the upper abdomen. The pain had developed suddenly the day before and was accompanied by nausea and vomiting. The days beforehand, her oral food intake had been less because of decreased appetite. Although the patient had no recent complaints of heartburn or regurgitation, she had had documented stomach complaints accompanied by nausea and vomiting for a longer period. Furthermore, she had a history of chronic obstructive pulmonary disease, microcytic anaemia of unknown origin, osteoporosis, diverticulosis of the sigmoid and knee surgery. She was not on any medication at that moment. On physical examination she was moderately ill, drowsy and pale. Blood pressure was 208/100 mmHg, pulse rate 100 beats/min. and body temperature 36.4 C. Her abdomen was markedly distended and on prolonged auscultation we could not detect bowel sounds. There was tenderness in the upper abdomen. On rectal examination brown faeces, without blood or melaena, were collected. Blood tests revealed a C-reactive protein level of 13 mg/l, 11.9 x 109 leucocytes, 156 x 109 thrombocytes, haemoglobin level of 9.4 mmol/l, sodium 139 mmol/l, potassium 3.2 mmol/l, chloride 107 mmol/l, urea 8.1 mmol/l, creatinine 78 mmol/l, alkaline phosphate 115 U/l, ASAT 28 U/l, ALAT 13 U/l, gGT 24 U/l, LDH 411 U/l, glucose 13 mmol/l, bicarbonate 20.5 mmol/l and lactate 1.2 mmol/l.

A supine chest X-ray (figure 1) was taken. An attempt to put a transoesophageal drain into the stomach was not successful because the distal oesophagus could not be passed. On the second day after admission to the hospital the patient suddenly developed dyspnoea, a temperature of 38.2 C, low blood pressure and a drop in oxygen saturation. She frequently vomited small amounts of dark-brown fluid. A second attempt was made to insert a drain into the stomach, which fortunately was successful and about four litres of dark fluid stomach contents could be aspirated. After this episode, contrast was given through the drain and intravenously and a computed tomography (CT) scan of the thorax was carried out (figure 2).