BACKGROUND Tension pneumothorax (TP) is a medical emergency resulting in air accumulation in the pleural cavity of the affected side. Later, this air applies pressure on the mediastinal structures, leading to a shift of these structures toward the contralateral side. This shift results in a picture of obstructive shock with a possibly fatal consequence if not detected and treated early. Treatment should not await radiological confirmation, and the red flags in the history and physical examination are enough to proceed with decompressing the affected hemithorax with a large-bore needle. Usually, patients with TP present to the Emergency Department with pleuritic chest pain and shortness of breath, but rare presentations are still possible. CASE REPORT We report a case of a 24-year-old male patient with TP who presented to the Emergency Department with severe epigastric abdominal pain with a clinical picture of acute pancreatitis. X-ray showed a right-sided TP. Immediately, we performed a needle decompression followed by chest tube insertion. Four days later, the patient was discharged home uneventfully. CONCLUSIONS In this case report, we aim to draw the attention of physicians in the Emergency Department to the need to consider the possibility of upper abdominal pain elicited by chest pathologies. Furthermore, we need to investigate the effect of TP on coronary perfusion.