A Patient With Recurrent Ovarian Cancer Presents With Acute Abdominal Pain

Ms. X is a 45-year-old with a history of recurrent stage 3c ovarian cancer, initially diagnosed in 2010. She underwent a total abdominal hysterectomy, bilateral salpingo-oophorectomy, omentectomy, appendectomy, small bowel resection, and staging procedure followed by 6 courses of IV Carboplatin and Taxol, which she tolerated without complication. She was without detectable disease until recently when her CT scan revealed suspicious lymph nodes and a 2cm pelvic mass. A PET scan confirmed this to be FDG avid. Her oncologist recommended that she be treated with IV Carboplatin/Avastin, which she began three months ago.

She received chemotherapy three days ago and called the office with complaints of abdominal pain, fever/chills, and back pain. She is brought into the clinic for evaluation with the CRNP. Her vital signs are outlined below:

• Pain score: 9/10, abdomen
• Temp: 101.5
• HR: 145
• BP: 145/82
• Resp: 24/labored

On exam she was pale and diaphoretic sitting on the table guarding her abdomen. When asked to lie back on the table she groaned in agony but was finally able to lie flat. She stated that movement made her pain worse. Her abdomen was acutely tender on gentle palpation and stated the pain radiated to her back. No CVA tenderness was appreciated during exam. Shortly into the exam, she began to feel ill and vomited twice and had one syncopal episode.

		Given the above, what is the clinical suspicion?   Gastroenteritis   Appendicitis   Gastrointestinal (GI) perforation   Pyelonephritis