Background: Giant inguino-scrotal hernias are unusual, and associated with duodenal perforation causing peritonitis is an extremely rare presentation. Case presentation: A 73 year old gentleman presented to the Emergency department (ED) with sudden onset of lower abdominal pain, bilious vomiting, and constipation. He had a huge right sided inguino-scrotal swelling. Computed tomography (CT) abdomen showed massive inguino-scrotal hernia containing pylorus, part of duodenum and loops of jejunum, ileum and large bowel upto descending colon as contents with signs of perforation. Labs were suggestive of sepsis. At emergency surgery, perforation of the second part of duodenum with generalized peritonitis was evident. Closure of the perforation and drainage was done as a damage control procedure and definitive hernia repair was deferred for a later period. Despite intensive-care, the patient succumbed to sepsis postoperatively. Conclusion: This is a rare presentation of duodenal perforation secondary to giant inguino-scrotal hernia causing biliary peritonitis ensuing in sepsis and death. We reviewed the literature on giant inguinal hernia, and especially those associated with duodenal perforation.