Abdominal emergencies in cancer patients: Diagnosis and management

Surgical oncologists are frequently asked to evaluate cancer patients with symptoms and signs suggestive of acute abdominal pathology. The traditional general surgical differential diagnosis must be considered in addition to conditions specific to the cancer patient. There are many factors unique to the cancer patient that may influence surgical decision making, such as immunosuppression, neutropenia, chemotherapy and radiotherapy, chronic pain and narcotic use, steroid use, and malnutrition. These factors may alter or mask the clinical presentation of these patients, compared to their non-cancer counterparts. As many of these patients and conditions meet the criteria for palliative care, consideration must be given to oncologic prognosis, quality of life, and the potential for symptom improvement; outcomes that are impossible to predict and infrequently reported in studies. This chapter focuses on the more common and unique conditions for which surgical consultations are requested. Bowel perforation may occur more frequently in cancer patients and is a known side effect of some chemotherapeutic agents. Treatment is primarily operative, but comfort care or non-operative treatment may be at times appropriate, as many patients are at extremely high risk for surgical complications and have limited survival. Bowel obstruction in patients with advanced or incurable cancer is another difficult situation which requires a tailored approach and in which controversy remains with regard to contraindications for surgical intervention. Neutropenia and abdominal pain may represent a wide variety of disorders and consideration must be given to neutropenic enterocolitis. This chapter also addresses the diagnosis and management of cholecystitis, biliary obstruction, gastrointestinal bleeding, and appendicitis in the cancer patient.