A 60-year-old woman with a history of alcohol abuse and hypertension presented to the emergency room because of increasing fatigue and shaking chills. Her temperature was 39.7°C (103.4°F) and her blood pressure was 90/60 mm Hg. Tenderness was present in the left upper and lower quadrants of the abdomen with guarding. Crepitus was noted along the left lateral side of the abdominal wall. Laboratory findings included a white blood cell count of 20 000/mm3 (20.0×109/L) with a leftward shift, abnormal results on liver function tests, anemia, a serum urea nitrogen concentration of 44 mg/ dL (15.5 mmol/L), and a creatinine level of 1.6 mg/dL (140 μmol/L), in addition to a prolonged prothrombin time.Roentgenograms of the abdomen and chest were obtained (Fig 1).
Pneumoretroperitoneum, pneumomediastinum, and subcutaneous emphysema secondary to sigmoid diverticulitis with extraperitoneal perforation.A plain x-ray film of the abdomen showed a calcified