The Korean Journal of Hepatology 2012;18:94-97 http://dx.doi.org/10.3350/kjhep.2012.18.1.94 pISSN: 1738-222X eISSN: 2093-8047 Case Report A case of emphysematous hepatitis with spontaneous pneumoperitoneum in a patient with hilar cholangiocarcinoma Jung Ho Kim, Eul Sik Jung, Seok Hoo Jeong, Ju Seung Kim, Yang Suh Ku, Ki Baik Hahm, Ju Hyun Kim, and Yeon Suk Kim Department of Internal Medicine, Gachon University Gil Hospital, Gachon University of Medicine and Science, Incheon, Korea An 80-year-old woman with hilar cholangiocarcinoma was hospitalized due to sudden-onset abdominal pain. Computed tomography revealed hepatic necrosis accompanied with emphysematous change in the superior segment of the right liver (S7/S8), implying spontaneous rupture, based on the presence of perihepatic free air. Although urgent percutaneous drainage was performed, neither pus nor fluids were drained. These findings suggest emphysematous hepatitis with a hepatic mass. Despite the application of intensive care, the patient’s condition deteriorated rapidly, and she died 3 days after admission to hospital. Liver gas has been reported in some clinical diseases (e.g., liver abscess) to be caused by gas-forming organisms; however, emphysematous hepatitis simulating emphysematous pyelonephritis is very rare. The case reported here was of fatal emphysematous hepatitis in a patient with hilar cholangiocarcinoma. (Korean J Hepatol 2012;18:94-97) Keywords: Cholangiocarcinoma; Rupture; Hepatitis; Necrosis; Pneumoperitoneum INTRODUCTION Emphysematous change in the liver can be seen in several clinical situations, such as liver abscesses caused by gas- forming bacteria, after sphincterotomy, and bowel infar- ction.1-3 Hepatic artery thrombosis after liver transplantation can sometimes lead to gas gangrene of the liver.4,5 Except for these incidental cases, there have been few reports of hepatic parenchymal emphysematous change. Futhermore, clinical outcome is reported to be very poor despite application of aggressive management. Radiologically, the features are similar to those of emphysematous pyelonephritis.6 We recently experienced an extremely rare case of emphyse- matous hepatitis accompanied in a patient with hilar cholangiocarcinoma. CASE REPORT An 80-year-old woman was admitted to Gachon Gil Medical Center due to severe right upper quadrant (RUQ) abdominal pain of 2 days, before w hich she had been diagnosed as hilar cholangiocarcinoma (Fig. 1). An endo- scopic retrograde biliary stent was placed for biliary drain- age 2 months prior to the current admission. She had no medical history, such as diabetes mellitus or biliary surgery. Symptoms related to cholangitis were resolved with biliary stenting and her general condition showed improvement. Because of her refusal to undergo surgical treatment, radiotherapy was applied after palliative biliary stenting. Computed tomography (CT) performed for simu- lating a radiation therapy taken 17 days prior to admission Received March 17, 2011; Revised August 4, 2011; Accepted September 2, 2011 Abbreviations: CT, computed tomography; ICU, intensive care unit; MRCP, magnetic resonance cholangiopancreatography; MRI, magnetic resonance imaging; RILD, radiation induced liver disease; RUQ, right upper quadrant Corresponding author: Yeon Suk Kim Department of Internal Medicine, Gachon Gil Hospital, 1198 Guwol-dong, Namdong-gu, Incheon 405-760, Korea Tel. +82-32-460-3778, Fax. +82-32-460-3408, E-mail; drkim@gilhospital.com Copyright Ⓒ 2012 by The Korean Association for the Study of the Liver This is an Open Access article distributed under the terms of the Creative Commons Attribution Non-Commercial License (http://creativecommons.org/licenses/by-nc/3.0/) which permits unrestricted non-commercial use, distribution, and reproduction in any medium, provided the original work is properly cited.