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The radiograph (fig 1) shows displacement of the liver and compression of intestinal loops by a tension pneumoperitoneum. After insertion of a 14 gauge angiocatheter through the abdominal wall, the abdomen deflated. Immediate laparotomy revealed a lateral duodenal perforation and intestinal infarction from the proximal jejunum to the proximal ileum. Endoscopic retrograde cholangiography (ERC) was difficult because of duodenal obstruction due to Waldenströem’s macroglobulinaemia (WM) involvement of the duodenum. Insufflated air probably caused duodenal pneumatosis and finally perforation. The air escaped into the retroperitoneum, peritoneum, and subcutaneous tissue. An increase in intra-abdominal pressure together with enlarged para-aortal lymph nodes resulted in compression of the vena cava inferior and splanchnic vessels, cardiac low output syndrome, and respiratory dysfunction. WM associated hyperviscosity because of circulating IgM paraprotein may have resulted in impaired microcirculation with segmental bowel infarction in a patient without symptoms of previous intestinal ischaemia. Despite rapid surgical intervention the patient died from refractory acidosis and gastrointestinal bleeding.

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