The process pump as turbine (PPAT) serves as a crucial component for recovering high-pressure energy from mediums used in chemical and refining processes. Ensuring the long-term safe and stable operation of PPAT in high-temperature and high-pressure environments is essential, with pressure pulsation being one of its most significant external characteristic indicators. This study investigates the evolution of vortex structure distribution and the generation and propagation mechanisms of pressure pulsation in a two-stage PPAT operating in turbine mode. Results indicate that the uniformity of the pressure coefficient (Cp) gradient distribution is poorer in the first stage runner compared to the second stage, with a larger distribution area of high-strength vortices. In the draft tube, vortex strength increases with rising flow rates, and the flow around the circular cylinder on one side gradually develops to both sides. In the two-stage diffusers, the primary source of pressure pulsation is the dynamic and static interference effect between the two impellers and the corresponding diffuser tongue. The interstage interference with a frequency of n*15fn is most pronounced in the inflow runner, gradually weakening along the flow direction, and ultimately disappearing in the draft tube. In addition, more low-frequency signals with a frequency of 0.5fn are captured in the draft tube under large flow conditions, which is mainly generated by the vortex band in the draft tube. The low-frequency pulsation energy is high and the attenuation is slow, which has a great destructive effect on the energy recovery system of the PPAT.