A 64-year-old man had a CT scan due to the development of abdominal distension during hospitalization in our chronic-phase ward after suffering a traumatic subarachnoid hemorrhage. The CT showed marked enlargement of the small intestine with intestinal emphysema as well as ascites retention, causing the patient to be referred to our department. Although his abdomen had markedly distended, there was no notable abnormality in his vital signs, etc. He was radiographically suspected of having an inner hernia, and underwent an emergency operation. Straw-colored ascites was observed in the abdominal cavity, and the small intestine had extensively distended. An abnormal 1×2 cm hiatus was detected in the mesentery near the terminal ileum, and the small intestine was incarcerated into the hiatus and kinked. While multiple emphysematous sites were also observed in the intestinal membrane, neither necrotic evidence nor perforation was found there. After the repositioning of the incarcerated intestine, the operation was finished with the suture closure of the abnormal hiatus. Mesenteric hiatus hernia, a rare disease in which the intestine invaginates into an abnormal hiatus in the mesentery and leads to intestinal obstruction, is less frequently reported in the elderly. A quick response is required with the possibility of this disease in mind in cases where ileus is encountered.

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A 33-year-old male with severe mental retardation was admitted to our hospital for frequent vomiting. He was diagnosed as having primary small bowel volvulus when abdominal computed tomography (CT) revealed a whirl sign in the small bowel loops around the superior mesenteric vessels. During the emergency operation, the small bowel was found to be twisted 360 degrees counterclockwise around the superior mesenteric vessels. The small bowel had caused some ischemic change but was not necrotized, so surgery involved only returning the axis rotations. However on postoperative day 29, the patient vomited again. We diagnosed primary small bowel volvulus recurrence because abdominal CT demonstrated a whirl sign. Under the diagnosis of recurrent small bowel volvulus, an emergency operation was carried out. In the same manner as the prior operation, the small bowel was twisted 360 degrees counterclockwise around the superior mesenteric vessels. After detorsion, we conducted bowel fixation according to Noble’s procedure to prevent a re-recurrence. Because there are a few reports of recurrence, the advantages of small bowel fixation are still uncertain. We suggest the necessity of fixation with Noble’s procedure in case of recurrence of primary small bowel volvulus.

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Ileus is a relatively rare disease among complications during pregnancy. We report herein on a case of strangulation ileus in a 17-week pregnant patient, together with discussion of the relevant literatures. A patient was a 30-year-old female, 0P, 0G with a history of myomectomy at the age of 28. Patient had symptoms of vomiting and abdominal pain at 17 weeks of pregnancy. Since abdominal enhanced CT revealed a decrease of intestinal blood flow and ascites, she was diagnosed as having strangulation ileus. Emergency surgery under general anesthesia revealed a long segment of necrotic small intestine, 150 cm of which was resected. The patient had a good clinical course and was discharged 12 days after surgery. There was no recurrence of ileus. The patient progressed through 39 weeks’ gestation to a normal spontaneous delivery without difficulty. There was no deformity and disorder of the newborn baby. We reviewed 174 cases of ileus during pregnancy in the Japanese literatures. The majority of ileus cases during pregnancy occurred in patients more than 31 years old (91 cases) and at more than 28 weeks of pregnancy (89 cases). Fetal death was observed in 10 cases. The selection of the best diagnostic method and decision regarding the treatment strategy is apparently important so as not to miss the best timing of the surgical intervention.

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We report herein on a case of a penetrated diverticulum in the distal ileum. An 88-year-old man developed lower right abdominal pain and vomiting one week after the onset of abdominal pain, and was transported to our hospital by ambulance. He exhibited signs of peritoneal irritation and high inflammatory markers (WBC 11,200/μL, CRP 21.54mg/dL) on arrival. Ascites was observed and mesenteric gas was noted on abdominal CT images along the right paracolic gutter starting from the ileocecum. The patient was diagnosed as having an ileal perforation and panperitonitis, and emergency surgery was performed. An approximately 15- to 20-cm section of the terminal ileum was red and thick, and a mesenteric abscess was found. A partial resection of the ileum and a loop colostomy were performed. A diagnosis of perforated ileal diverticulum was made from the histopathological findings. The postoperative outcome was good and the patient was discharged in good condition on the second month after surgery. Small bowel diverticulosis is a rare disease, but can become serious when complicated by perforation. The detection rate of pneumoperitoneum on both abdominal X-ray and abdominal CT images is low in the first 4 hours after perforation, which often makes preoperative diagnosis difficult.

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A 34-year-old male presented at the emergency department with a left upper chest stab wound. CT examination was performed and he was diagnosed as having left hemopneumothorax and a diaphragmatic hernia. A drainage tube was inserted into his left pleural cavity, but there were no persistent air leaks or hemorrhage. Surgical treatment was planned to remove of hematoma and explore lung injuries. An operation was performed and we found no lung injuries but we did identify diaphragmatic injuries and gastric injuries. The postoperative period was uneventful. Sometimes a localized wound makes us overlook other systemic injuries. In a case of penetrating injury with a diaphragmatic hernia, we must consider gastrointestinal injuries and perform an emergency laparotomy.

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A pseudoaneurysm is a life-threatening complication after pancreaticoduodenectomy. Interventional radiology is commonly considered as the first-line therapy for a ruptured pseudoaneurysm. However, the interruption of hepatic arterial flow by embolization involves some risk of liver dysfunction or abscess formation. To avoid arterial insuf-ficiency of the liver, a stent-assisted coiling (SAC) technique has been used recently to treat the rupture of a pseudoaneurysm arising in a major artery supplying arterial blood to the liver. We report herein on three cases in which SAC was performed for a ruptured pseudoaneurysm after pancreaticoduodenectomy. In the first case in which a pseudoaneurysm developed after hepato-pancreaticoduodenectomy, SAC was not performed in a timely fashion. In the second case, there was misidentification of the location of the pseudoaneurysm. The third case underwent SAC successfully, though the preparation required time. Liver dysfunction was not observed in any of the cases. We believe that the key to the success of this technique is to decide promptly to apply SAC and cooperate closely with interventional radiologists during embolization.

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Splenic vein thrombosis is a rare disease and it is generally difficult to diagnose. This condition is commonly silent clinically, but may cause hypersplenism or gastrointestinal hemorrhage due to gastric varices. The most common causes are pancreatitis, pancreatic carcinoma and blood coagulation abnormality. We report herein on a rare case of idiopathic splenic vein thrombosis. An 82-year-old woman was admitted to the hospital with peritonitis of unknown origin. She had a stomachache. Her laboratory studies on admission showed an inflammatory reaction. An abdominal CT scan demonstrated ascites, increased mesenteric fat density, and a small splenic vein thrombosis. We could not identify the cause of the peritonitis and we started her on antibiotic treatment. However, the inflammatory reaction did not improve. On the 10th hospital day a follow-up CT scan was performed which demonstrated that the splenic vein thrombosis was enlarged, with increased ascites. Therefore, we began to treat her with antithrombotic therapy under a diagnosis of peritonitis caused by splenic vein thrombosis. The inflammatory reaction improved and her symptoms disappeared with the antithrombotic therapy. She was diagnosed as having idiopathic splenic vein thrombosis because she did not have a medical history of pancreatitis, pancreatic carcinoma or any blood coagulation abnormality.

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A 65-year-old man was admitted to our hospital with an intermittent lower abdominal pain and a fever. The laboratory data showed white blood cell and C-reactive protein were slightly elevated (WBC: 10,300/µL, CRP：6.33 mg/dL). Computer tomography (CT) of the abdomen showed a radiodense linear foreign body measuring 46 mm that extended transmurally through the sigmoid colon wall. On the same day, we performed emergency partial resection of sigmoid colon and colostomy at sigmoid colon. The removed fish bone was 57 mm long. The incidence of foreign body perforation is no more than 1% because almost all foreign bodies are spontaneously excreted. In Japan, fish bone perforation is the most common disease among foreign body perforations because of the dietary habits of the Japanese general population. However, it is extremely rare that a 57 mm fish bone can pass through the digestive tract and reach the sigmoid colon without any recognition and/or symptoms. CT scan is useful and a detailed history taking is important for diagnosis.

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We report herein on a case of hemorrhage from an ulcer in duodenal diverticulum treated with endoscopic electrocoagulation. Hemorrhage from the duodenal diverticulum should be suspected when a definite bleeding source in the esophagus, stomach or duodenum cannot be identified. In this case, first of all, we tried to stop the bleeding by clipping the diverticular he morrhage. However, we were able to control the hemorrhage more easily with hemostatic forceps than a clip, because there was no space in the diverticulumto use the clip. There were no adverse effects in this case. Furthermore, it is suggested that oral administration of NSAIDs can cause bleeding from ulcers or erosions of the duodenal diverticulum.

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A 56 year-old man was delivered to our hospital by ambulance, complained of severe persistent epigastric pain. At one hour since the symptom onset, epigastric tenderness, vomiting, and watery diarrhea were noted. Enhanced computed tomography revealed complete occlusion of the superior mesenteric artery. Abdominal angiography was performed 3 hours after the onset of symptoms. Thrombolytic treatment was performed, and the thrombus was dissolved with 660000 units of urokinase. Abdominal pain was subsequently relieved and we started anticoagulant therapy. No blood clot formed after the treatment, but abdominal pain still remained and intestinal hemorrhage was found. Capsule endoscopy was performed to exclude intestinal ischemia on the 5th day. There was no mucosal ischemia, so the patient started oral intake on the 6th day. The capsule endoscopy was considered to be a non-invasive survey and useful for excluding intestinal ischemia after thrombolytic treatment.

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A woman in her 80s was admitted with a three-day history of a poor appetite and a fever. Antibiotics were administered due to the presence of a strong inflammatory reaction, but poor improvement was seen. An abdominal contrast-enhanced CT scan showed liquid with air behind the ascending colon, pancreas and duodenum. A retroperitoneal abscess secondary to perforation of the gastrointestinal tract was diagnosed, and emergency surgery was chosen, because performing a percutaneous puncture was considered to pose a high risk. The pancreas and duodenum were inflamed, and the point of perforation was not found. Intraperitoneal irrigation and drainage were performed. Continuous drainage was successful, without biliary leakage, although it took some time for the duodenal diverticular fistula to close. We herein report on a case of perforated duodenal diverticulum successfully managed with drainage, and suggest that less-invasive drainage may be a useful approach to treatment in selected cases.

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An 88-year-old woman was admitted to our hospital after she erroneously swallowed a denture. Chest radiography showed a denture with a clasp in the lower mediastinum. Under endoscopic observation, we found the denture stuck in the right-hand wall of esophagus. We felt resistance to endoscopic removal that left an exposure of muscle layer. Computed tomography revealed subcutaneous, mediastinal, and retroperitoneal emphysema. Under a diagnosis of esophageal perforation, the patient underwent surgery. The ports were placed on her right thoracic wall in the left decubitus. The denture was removed by cutting the esophagus wall with an ultrasonic coagulation and incision system. The incisional site of the esophageal wall was closed with simple sutures and patched with an absorbent organization reinforcing material. The postoperative course was uneventful and the patient was discharged on the 19th postoperative day, following minimally invasive surgery with thoracoscopic repair.

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A 70-year-old male suddenly lost consciousness and was admitted to the emergency department of our hospital. A computed tomography (CT) scan revealed a high degree of liquid effusion in the bursa omentalis and around the liver and spleen, and an arterial aneurysm of the right gastric artery, which was about 7 mm in diameter, but the point of extravasation could not be detected. A diagnosis of acute hemoperitoneum was made, and an emergency laparotomy was performed. We noted about 1,800 g of blood and clots in the abdominal cavity and a hematoma around the lesser omentum. The hemorrhage was thus diagnosed to have occurred from a ruptured aneurysm of the right gastric artery. We performed partial resection of the lesser omentum near the area in which hemorrhage was observed. The patient’s postoperative course was uneventful, and he was discharged on the 18th postoperative day. A pathological examination revealed mild arteriosclerosis, but no evidence of segmental arterial mediolysis. We herein report on the details of this case with a review of the literature.

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A 48-year-old man had constipation for two days, and he was ambulated to our emergency room for sudden onset of abdominal pain. Panperitonitis due to perforation of the sigmoid colon was suspected, and an emergency operation was performed. There was large amount of contaminated ascites in the peritoneal cavity, and a round perforation (about 10mm in diameter) was found in the wall of the sigmoid colon. Partial resection of the sigmoid colon was carried out, and a colostomy was placed at the oral side.

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We experienced a rare case of transomental sac hernia invagination through a hiatus of the greater and smaller omentum and which had prolapsed to the abdominal free space through a hiatus of the lesser omental bursa, resulting in strangulation. A 16-year-old female was admitted to our hospital with prolonged pericardial pain. The X-ray findings revealed the niveau sign in the small intestine. Computed tomography showed dilatation of the small intestine due to obstruction and decrease of enhancement effect of the intestinal wall. Because of these radiological findings and the lack of the past history of laparotomy and injury, an emergency laparotomy was performed under a diagnosis of strangled intestinal ileus of the small intestine. At the time of the laparotomy, the ascending colon was free from the posterior abdominal wall and about 150 cm of the small intestine had invaginated through the defect of the greater and smaller omentum and prolapsed from the hiatus of the small omental bursa, locked by Bauhin’s valve. The ileocecal and the necrotic small intestine was resected. The postoperative course was uneventful. Internal hernias, such as transomental hernias, must be kept in mind as a high risk of strangulated ileus and should be treated as an emergency.

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A 17-year-old man with mental retardation due to autism visited a local internal hospital for fever and abdominal pain. Abdominal X-ray showed the bowel obstruction foreign bodies in the lower abdomen. He was brought to our hospital by ambulance. His abdomen showed peritoneal signs and the abdominal CT revealed foreign bodes in the small bowel and free air and fluid collection in the ileocecal region. We diagnosed ileocecal perforation due to foreign bodies and performed an emergency operation for removal of the foreign bodies and small bowel resection. His postoperative course was good and he went back to his home following discharge. But he had ileus because of the foreign bodies after about a month from the first operation and he underwent a laparotomy again. However in the case of pic, it is important to identify the foreign bodies, but it is difficult to get information about foreign bodies from patients with mental retardation. Therefore, effective communication with the family and caretakers of these patients is important. For the prevention of pica, it is necessary that cooperation with many occupational descriptions should include the family and the psychiatrist.

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A 71-year-old man had undergone a mediastinoscopy-assisted esophagectomy with gastric conduit reconstruction for T1 esophageal carcinoma and feeding jejunostomy for nutritional support in the left lower abdomen 6 years previously. The patient presented with the respiratory obstruction due to laryngeal spasm after extubation immediately postoperatively and entered a vegetative state because of brain hypoxia. The feeding jejunostomy tube used a 14-Fr urethral balloon catheter for 6 years after the operation. Sudden prolapse of the jejunostomy occurred without incident. Markedly discolored intestine at the site of the jejunostomy pointed to bowel necrosis. An emergency laparotomy was performed. The strangulated jejunum was resected, and a new jejunostomy was constructed using an 8-Fr elemental diet tube at the anal side of the functional end-to-end anastomosis. The resected specimen had no tumor, but all layers of the incarcerated jejunum were necrotic. Although this complication is a rare event, we report herein on a case of prolapse and incarceration caused by a feeding jejunostomy tube.

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Gastroepiploic artery aneurysms constitute only 0.4％ of all aneurysms. Abdominal hemorrhages due to ruptured aneurysms are rare, and are usually treated with laparotomy or endovascular intervention. We report herein on a case of a ruptured left gastroepiploic artery aneurysm treated with single-incision laparoscopic surgery (SILS). A 75-year-old man with atrial fibrillation and on warfarin anticoagulation therapy was hospitalized with acute abdominal pain. Preoperatively, abdominal CT scan verified a ruptured left gastroepiploic artery aneurysm with abdominal hemorrhage, but extravasation of the contrast agent was not detected. Since performing a complete coil embolization of the aneurysm seemed to be difficult and the vital signs of the patient were stable, we performed SILS for the ruptured aneurysm. The patient was discharged from our hospital after four days without any postoperative complications. Our experience suggests, in case the location of the aneurysm is confirmed and the patient’s condition is stable even if the culprit lesion has already ruptured, minimally invasive SILS can be a feasible approach for treatment of ruptured visceral artery aneurysms.

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Cases of mesenchymal tumors such as gastrointestinal stromal tumors or leiomyosarcomas can be distinguished from rare cases of small intestinal leiomyosarcomas by determining the levels of c-kit antibodies in patients with these tumors. A 64-year-old man was referred to our department from another hospital because of intermittent abdominal pain with onset of one month previously. Abdominal computed tomography showed intussusception of the small intestine, for which emergency partial resection of the small bowel was performed. The tumor was diagnosed as a leiomyosarcoma of the jejunum. We present herein on this rare case of small intestinal leiomyosarcoma presenting as intussusception in an adult.

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We herein report on the case of a 55-year-old male who exhibited masses in one lung and one adrenal gland. The patient presented to the hospital with anemia and abdominal pain, and CT consequently revealed a lung tumor, adrenal tumor and two sites of intussusception. The intussusception was suspected to have been caused by the presence of jejunal metastatic tumors, and emergency surgery was performed in our hospital on the same day. Intussusception and five metastatic tumors were found in the small intestine；therefore, partial resection of the small intestine was performed. The pathological diagnosis was pleomorphic carcinoma, and jejunal metastasis of the lung cancer was suspected. However, the patient refused treatment for the lung cancer and died six months after the operation. Intussusception is rare in adults, although it may occur in the end stage of cancer. While surgeons may hesitate to perform surgery due to the advanced stage of the primary cancer, surgical intervention may yield a favorable outcome and improve the patient’s quality of life.

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A 68-year-old woman was referred to our hospital for abdominal pain. Her past history included Hartmann’s procedure for sigmoid colon diverticulitis 2 years previously. A parastomal hernia was detected one year after the operation, however, she had been on steroids and had no trouble with her stoma care and was followed up conservatively. Abdominal computed tomography confirmed an incarcerated parastomal hernia, and she underwent emergency surgery. After successful reduction of the parastomal hernia, intestinal resection was not necessary. Relaxing incisions were undertaken at the aponeurosis of the external abdominal oblique muscle and the rectus abdominis muscle. We exfoliated between the inner and external abdominal oblique muscle. Fascial repair of the parastomal defect was performed using the components separation technique. The patient’s post-operative course was uneventful. We report herein on a case of incarcerated parastomal hernia repaired by the components separation technique. This method was effective in the case of a parastomal hernia in which the use of mesh should be avoided.

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We report herein on a case of nonocclusive mesenteric ischemia (hereinafter NOMI) we experienced for which intraoperative endoscopy was effective to determine the therapeutic strategy. The patient was a-70-year old man. As a symptom of vomiting developed during his hospitalization in the department of neurosurgery of our hospital due to head trauma, the patient was referred to our department. With portal gas and intramural emphysema in the small intestine observed on abdominal CT, emergency surgery was conducted due to suspected intestinal necrosis. While the patient was diagnosed as having NOMI due to discontinuous reddening and edema observed in the jejunum, intraoperative endoscopy was performed because the viability of the intestinal canal was not clear. Even though an irregularly-shaped shallow ulcer, reddening and edema were recognized on the mucosal side, resection of the intestine was not conducted due to the observation of lack of necrosis. We report herein on our case with some bibliographic considerations.

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A 10-year-old boy with fever and diarrhea was diagnosed as having acute enteritis, for which he received medication at a nearby clinic. However, because his symptoms did not improve, he was referred to our hospital. Enhanced computed tomography revealed a huge abscess in the right anterior pararenal space and he underwent immediate surgery for perforated appendicitis. Retroperitoneal abscess drainage was performed laparoscopically via the right paracolic sulcus before displacing the iliac colon and resecting the appendix. A closed drainage catheter was placed after adequate lavage. Intraoral intake started on postoperative day 2, and the drainage catheter was removed on postoperative day 5. The postoperative course was good, and the patient was discharged on postoperative day 11 with no apparent infection or abscess formation. Laparoscopic appendectomy is minimally invasive, rarely causes postoperative wound infection, and enables abscess drainage and lavage with a good operative field, making it a useful surgical procedure for cases of perforated and/or complex appendicitis accompanied by an abscess.

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A 74-year-old woman visited our hospital because of periumbilical abdominal pain and redness of the skin. An abdominal abscess due to a fish bone was diagnosed preoperatively based on the computed tomography. An omental abscess was found and partial resection of the omentum was performed in an emergency operation. A bone fish was identified in the abscess. The perforation site was not identified, but it was believed that the fish bone had penetrated from the transverse colon into the omentum. The patient was discharged 7 days after the operation without event.

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A 58-year-old man who had undergone abdominal surgery for tuberculous peritonitis developed abdominal pain and vomiting. Computed tomography revealed an adhesive intestinal obstruction without strangulation. We began conservative treatment by inserting an ileus tube, but the tube could not be passed beyond the upper jejunum, and decompression was insufficient. Seven days after admission, the abdominal pain increased, and surgery was performed. There was no intestinal necrosis, and we performed only an adhesiotomy. Two days later, we removed the ileus tube, but massive melena and hemorrhagic shock occurred later that night. Dynamic computed tomography revealed contrast extravasation at the upper jejunum, and thus a small bowel hemorrhage was diagnosed. We performed a jejunectomy, and hemostasis was achieved. Pathological examination revealed a non-specific ulcer with serosal inflammation and changes that were attributed to external force exerted by the ileus tube. This is the second report of a small bowel ulcer hemorrhage caused by an ileus tube, the risk of which we should be aware of during its insertion.

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A 71-year-old male, and a habitual heavy drinker, developed type A acute viral hepatitis, which proceeded to acute-on-chronic type hepatic failure. Though plasma exchange with hemo-filtration-dialysis therapy and steroid pulse therapy were performed, he also had severe acute pancreatitis, and died. Age and chronic liver injury due to the habitual heavy drinking were considered to have influenced the severity of the viral hepatitis A. These factors might have disturbed the normal hepatic cell regeneration, and led to the poor clinical course with multiple organ failure. Elderly patients with chronic liver injury should be advised to be careful to avoid additional liver damage.

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A 75-year-old woman was admitted to our hospital with severe abdominal pain and hypotension after ingesting a laxative to prepare for a colonoscopy. Emergency colonoscopy showed a sub-circular tumor in the rectum and dilation of colon with dark red discoloration was observed in the oral side of the tumor, based on which we diagnosed the patient as having obstructive colitis. Because of the poor general condition of the patient, we determined that emergency surgery would be difficult. Therefore, we tried decompression using a colorectal tube. Her general condition improved, however, emergency surgery was performed because perforation occurred on the 17th day. Intraoperatively, ulceroinflammatory lesions were observed reaching up to the ascending colon, so a total colectomy and ileostomy were performed. Not many reported cases of colorectal tube placement for this disease have appeared so far, and emergency surgery has been performed in many cases. In our case, we considered that there was a certain significance in the colorectal tube placement as a symptomatic treatment to wait for the recovery of the patient’s general condition. For patients in whom colonic stenosis is suspected, taking the occurrence of this disease into consideration, we should carefully think about administering colon-clearing laxatives.

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A 77-year-old man was admitted to our hospital with abdominal pain. His past history included hypertension, angina pectoris, atrial fibrillation, stroke, chronic renal failure, and diabetes mellitus. On examination, muscular abdominal defense was detected. Blood studies showed evidence of severe inflammatory response. Computed tomography showed massive free air in the abdominal cavity, gallbladder and hepatic ducts. Under a diagnosis of a gastrointestinal perforation with an internal biliary fistula, an emergency operation was performed. Intraoperatively, dirty ascites and perforation of the gallbladder were seen. No perforation site or fistula was observed in the digestive tract. A simple cholecystectomy was performed. In Japan, only 3 cases of emphysematous cholecystitis perforation with air in the abdominal cavity and hepatic ducts have been reported. We report herein on this interesting case because of the difficulty in obtaining a preoperative diagnosis.

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An 83-year-old woman with a history of chronic cardiac failure and atrial fibrillation visited the emergency outpatient department of our hospital with abdominal pain and dyspnea. On presentation, she was conscious and alert, with a blood pressure of 82/62 mmHg, heart rate of 100 beats/min (irregular), oxygen saturation (SpO2) of 87%, and body temperature of 34.9 degrees centigrade. No abdominal tenderness was noted, but a fist-sized mass was palpable in the left groin. Since abdominal contrast-enhanced computed tomography (CT) showed findings of small bowel incarceration and superior mesenteric artery occlusionin the left groin, she underwent an emergency laparotomy. The intraoperative findings showed an incarcerated left femoral hernia and ischemic changes with findings of necrosis in the region from the small bowel to the right colon. Massive small bowel resection, right colectomy, and fistula formation in the small bowel and the transverse colon were performed. After surgery, she experienced complications with the central venous catheter and developed urinary tract infections, both of which resolved with conservative therapy. On the 53rd disease day, she was transferred to a chronic care hospital. We report herein on an extremely rare case of incarcerated femoral hernia with superior mesenteric artery occlusion together with reference to the relevant literature.

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A 77-year-old woman who was bedridden with dementia developed a fever. Chest radiography and abdominal computed tomography revealed intraperitoneal free air. Under the diagnosis of acute peritonitis caused by intestinal perforation, a laparotomy was performed. No abnormalities were found anywhere along the total length of the intestine. However, on internal examination, pus was detected in the uterus. Therefore, generalized peritonitis due to pyometra with no perforation was diagnosed. Peritoneal lavage and drainage were performed. This disease should be kept in mind as a possible cause of acute abdomen in older women, and courses of treatment should be decided carefully.

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