Jung Ho Kim, et al. Rare case of emphysematous hepatitits 95 A B Figure 1. Computed tomography (CT) and magnetic resonance imaging (MRI) findings on initial diagnosis. (A) Coronal contrast- enhanced CT scan showing ductal wall thickening with enhancement in the hilar portion of the extrahepatic bile duct (black arrow). Dilatation of the right intrahepatic bile duct without separation of the second-order branch of the right intrahepatic duct was noted, suggesting a type IIIa Klatskin tumor. (B) Magnetic resonance cholangiopancreatography (MRCP) demonstrated severe narrowing of both common hepatic ducts and the right first-order intrahepatic duct (white arrow), with marked dilatation of the right intrahepatic duct, as seen on CT. revealed ideal placement of an endoscopic retrograde biliary peritonitis impression; however, no fluid was drained. A drainage stent (Fig. 2). She received 9 times of radiotherapy diagnosis of emphysematous hepatitis with spontaneous with a total dose of 16.2 Gy (1.8 Gy×9 fractions). rupture into the peritoneal cavity was made. On admission, she was conscious and acutely ill in On the second day of admission, aggravated laboratory appearance. Her vital signs included a temperature of tests were noted as follows: WBC 26,000 mm3, aspartate Figure 2. CT performed for simulating radiation therapy. Axial contrast-enhanced CT scan revealing dilatation of the right intrahepatic bile duct without separation of the second-order branch of the right intrahepatic duct. There was no evidence of liver infection. Endoscopic retrograde biliary drainage is also visible (black arrow). 36.7℃, a heart rate of 100 beats/min, a blood pressure of 120/70 mmHg, a respiratory rate of 18 breaths/min, and an oxygen saturation of 94% on room air. Her sclera was icteric and her liver was palpable approximately 2 cm below the right costal margin. Right upper quadrant tenderness of the abdomen was present. The spleen was not palpable. Initial complete blood count showed a white blood cell count of 36,130 mm3, hematocrit of 28.2%, and hemoglobin of 9.3 mg/dL. Blood urea nitrogen was 34.9 mg/dL and creatinine was 1.4 mg/dL. C-reactive protein was 26.56 mg/dL. On liver function tests, aspartate transaminase of 882 IU/L, alanine transaminase of 257 IU/L, alkaline phosphatase of 464 IU/L, and total bilirubin of 17.9 mg/dL. Prothrombin time was normal. Abdominal CT scan demonstrated hepatic parenchymal emphysema measuring approximately 6.3×4.4 cm in the superior segment of the right liver (S7/S8) with pneumoperitoneum finding in the perihepatic space (Fig. 3). Urgent percutaneous drainage was attempted under the