LAUSR

A 72-year-old woman with atrial fibrillation was transferred to our hospital for acute pancreatitis of unknown etiology. One day before her transfer, she experienced upper and lower abdominal pain and was admitted to the previous hospital. Previous computed tomography (CT) showed swelling of the pancreas head and peripancreatic fluid collection (Picture 1), and she was diagnosed with acute pancreatitis. After hospitalization, anuria and acidosis continued, and she was transferred to our facility. After the transfer, the acidosis and anuria continued (Prognostic score 3, CT grade 2 calculated by the Japanese guidelines for the management of acute pancreatitis: Japanese Guidelines 2015) (1), and her laboratory data on admission were as follows: pH, 7.219 (range: 7.350-7.450); serum amylase, 2,033 U/L (range: 44132); serum creatinine, 2.10 mg/dL (range: 0.65-1.07). CT performed in our hospital showed gas gangrene of the total pancreas in two days after the previous CT scan (2, 3) (Pictures 2, 3; white arrowheads) and an impaired blood flow to a large portion of the small intestine, parts of which were perforated, as suggested by the presence of free air in the abdominal cavity. Based on these clinical findings, nonocclusive mesenteric ischemia (NOMI) was considered the cause of this pancreas gas gangrene. She died two days after her hospitalization. Klebsiella pneumoniae were detected in the arterial and venous blood and ascites. We should bear in