Hemorrhagic Pancreatitis Leading to Pneumoperitoneum and Septic Shock: A Rare Surgical Mimic

Hemorrhagic pancreatitis is an uncommon but potentially fatal complication of acute pancreatitis, as deterioration can be very rapid.The occurrence of pneumoperitoneum without evidence of hollow viscus perforation or pancreatic gas gangrene further represents exceptional diagnostic and surgical dilemmas.We report a rare case of a 70-year-old man with a history of chronic pancreatitis complicated by pancreatic duct stenosis who presented with epigastric and right hypochondrial pain, elevated pancreatic enzymes, and imaging supporting acute-on-chronic pancreatitis.The patient had progressive clinical deterioration despite normalization of serum pancreatic enzyme levels.Repeat imaging demonstrated extensive pneumoperitoneum, raising concern for perforated viscus, and the patient underwent emergency exploratory laparotomy.Surgery revealed extensive infected hemorrhagic fluid, multiple loculated collections, pyogenic membranes, and diffuse hemorrhagic pancreatitis, but no gastrointestinal (GI) perforation was identified.Despite intensive supportive management and surgical intervention, the patient developed progressive multiorgan failure and died.This case highlights the limitations of relying on pancreatic enzyme trends to assess disease progression and demonstrates that pneumoperitoneum may rarely occur in severe complicated pancreatitis without an identifiable GI perforation or definitive source of free intraperitoneal air.Clinical status, inflammatory markers, imaging findings, and hemodynamic changes should therefore be integrated rather than relying on pancreatic enzyme trends alone when evaluating patients with severe pancreatitis.