A 78-year old man who presents with four days of abdominal pain, constipation, abdominal distension, and shortness of breath. Sounds like a normal day in the ED. Here’s a little extra, he’s also hypotensive and hypoxic. Something is amiss in his abdomen and it’s nothing on your usual top 10 differential diagnosis, but he is heading toward a quick and painful death. It’s up to you to figure out the issue and save the day.