When free air misleads: pneumoperitoneum from a ruptured pyogenic liver abscess

Pyogenic liver abscess (PLA) is a severe condition with mortality rates of 10%-19%. Spontaneous rupture occurs in about 5% of cases and carries much higher mortality. Rarely, ruptured PLA presents with pneumoperitoneum, mimicking hollow viscus perforation. We report a 48-year-old man with chronic gastric ulcer disease who presented with fever, malaise, nausea, and abdominal distension two weeks after endoscopic hemostasis. He rapidly deteriorated with septic shock and peritoneal signs. Ultrasound was inconclusive, and repeat X-ray revealed pneumoperitoneum. Laparotomy found purulent peritonitis from a subcapsular abscess in segment II, perforating both diaphragmatic and visceral hepatic surfaces. <i>Enterococcus faecalis</i> was isolated, and antibiotics administered. A secondary abscess in segment VII was later drained percutaneously. The patient recovered after 37 days. This case highlights the diagnostic challenge of ruptured PLA and the value of combined surgical and minimally invasive management.