A 62 years male retired labourer and chronic alcoholic for 30 years was diagnosed with adenocarcinoma pancreas encasing the main portal vein and infiltrating the duodenum. The joint clinic decision was taken to give neoadjuvant chemotherapy of 8 cycles 5-Fluorouracil, oxaliplatin, irinotecan followed by hypo fractionated radiotherapy of 25 Gy, 5 fractions.

Patient presented to the emergency department with severe epigastric pain that was unresponsive to standard analgesic regimens. He was hemodynamically stable on admission. Physical examination revealed localized tenderness in the right hypochondriac and epigastric regions.

The initial differential diagnosis included liver abscess, bowel obstruction, gastrointestinal perforation, intussusception, and a large intra-abdominal mass compressing vital structures. A cardiac cause for the abdominal pain was ruled out. Based on clinical assessment, a provisional diagnosis of acute abdomen was made, and the patient was referred to the Department of Palliative Medicine for optimization of pain management. Concurrent symptoms included persistent vomiting and constipation.

An erect abdominal X-ray (Fig. 1) demonstrated free air under the right hemidiaphragm, suggestive of hollow viscus perforation. Emergency surgical consultation was obtained, and the patient was taken for exploratory laparotomy by the surgical oncology team. Intraoperatively, a duodenal perforation was identified. It was managed with an omental patch repair, and a palliative gastrojejunostomy was performed to bypass the obstruction.

Postoperatively, the patient developed a burst abdomen, which was managed conservatively. He remained under regular follow-up with the surgical and medical oncology teams for continuation of palliative chemotherapy. Despite these efforts, the patient succumbed to gram-negative sepsis one month later, following chemotherapy administration.

X ray abdomen erect film. This X ray shows that there is air under the right cusp of the diaphragm, pointing to possibility of perforation