A 68-year-old male with past medical history of diabetes mellitus and two previous episodes of mild acute pancreatitis was admitted to the hospital with a 12-hour history of severe epigastric pain and nausea. He reported no recent alcohol consumption, and current medication was metformin. On initial physical examination, he had a temperature of 38.5°C, a heart rate of 94 beats per minute, and a respiratory rate of 26 breaths per minute. The patient had moderate epigastric abdominal tenderness without peritoneal irritation. Laboratory examination revealed white blood cell count 16,100/mm 3 , hematocrit 46.40%, glucose 26.9 mmol/L, serum amylase 1564 U/L, serum lipase 4116 U/L, serum alanine aminotransferase 380 U/L, serum lactate dehydrogenase 421 U/ L, alkaline phosphatase 248 U/L, direct bilirubin 3.0 mg/dL, BUN 12 mg/dL. Calcium, triglyceride, and electrolyte values were normal. Electrocardiography (ECG) and chest X-ray were normal. He was treated with intravenous fluids and pain relief medication. Several hours after admission the patient deteriorated, became hypotensive and dyspneic with increasing epigastric pain and peritoneal irritation, and required mechanical ventilation. Contrast-enhanced computed tomography of abdomen revealed gas in the portal vein, gastric pneumatosis, necrosis of the pancreas and pneumatosis intestinalis (Panels A and B).