Gas-forming Pyogenic Liver Abscess Mimicking Gastric Perforation in a Patient With Diabetic Ketoacidosis and Subsequent Rupture: A Case Report.

A 53-year-old man with uncontrolled diabetes presented with fever and diabetic ketoacidosis. Computed tomography revealed a large hepatic lesion containing mottled gas, but the origin was uncertain, delaying drainage and raising concern for gastric perforation. Next-morning computed tomography showed hepatic gas and free intraperitoneal air, yet abdominal findings were minimal. During percutaneous drainage planning, he developed sudden abdominal pain and septic shock, illustrating the rapid, life-threatening course of gas-forming pyogenic liver abscess. Urgent laparoscopy confirmed rupture; Klebsiella pneumoniae was isolated. This case highlights diagnostic challenges and need for prompt reassessment and source control. Uncontrolled diabetes and ketoacidosis likely accelerated gas-forming pyogenic liver abscess rupture.