Beyond the bleed: bedside ultrasound reveals tension pneumoperitoneum in a patient with suspected acute variceal bleeding.

Coffee-ground emesis in a patient with cirrhosis frequently triggers an emergency pathway for suspected variceal upper gastrointestinal bleeding (UGIB) and urgent endoscopy. However, diagnostic anchoring may delay recognition of alternative life-threatening conditions. A 68-year-old man with decompensated liver cirrhosis (Child-Pugh B), large-volume ascites, COPD GOLD grade 3 with chronic global respiratory failure developed shock and recurrent vomiting of coffee-ground material and fresh blood on a gastroenterology ward. Variceal bleeding was initially suspected. After transfer to ICU, he deteriorated with severe hypoxaemia and progressive ventilatory compromise. A markedly tense, distended abdomen prompted point-of-care ultrasound (POCUS), which demonstrated extensive pneumoperitoneum. Emergency percutaneous decompression via a standard paracentesis needle evacuated free intraperitoneal air under tension with rapid respiratory improvement. Urgent oesophagogastroduodenoscopy showed no evidence of upper gastrointestinal perforation or variceal bleeding. Computed tomography confirmed diffuse pneumoperitoneum and suggested pathology at the ileocaecal transition; surgery revealed perforation of the ascending colon with localized peritonitis. This case highlights the importance of whole-patient reassessment before emergency endoscopy, early use of POCUS when abdominal findings are discordant, and interdisciplinary crisis management. Needle decompression can be lifesaving as a bridge to definitive surgery in tension pneumoperitoneum.