When Blood in the Belly Stops the Bowel: Hemorrhagic Ascites Causing Ileus.

Ascites is a common cause of abdominal distension and may contribute to increased intra-abdominal pressure and impaired gastrointestinal motility. Although ileus is more commonly associated with postoperative states, infection, medications, or electrolyte disturbances, massive ascites can rarely result in a functional bowel obstruction through elevated intra-abdominal pressure. We present a patient with a low serum ascites albumin gradient (SAAG) secondary to a pancreatic ductal leak in the setting of chronic pancreatitis who developed progressive abdominal distension, nausea, and obstipation. Imaging demonstrated diffuse bowel dilation without a clear transition point or evidence of mechanical obstruction. In this case, pancreatic ascites was the primary driver of intra-abdominal hypertension. Following large-volume paracentesis and endoscopic retrograde cholangiopancreatography (ERCP) intervention, the patient experienced rapid symptomatic improvement and return of bowel function, supporting a diagnosis of ascites-induced ileus secondary to intra-abdominal hypertension. This case highlights an uncommon complication of pancreatic ascites and underscores the importance of recognizing elevated intra-abdominal pressure as a reversible cause of ileus.