A 69-year-old man is brought to the emergency department because of severe abdominal pain radiating to his left flank for 30 minutes. He is weak and has been unable to stand since the onset of the pain. He vomited twice on the way to the hospital. He has not passed stools for 3 days. He has hypertension, coronary heart disease, and peptic ulcer disease. He has smoked half a pack of cigarettes daily for 46 years. Current medications include enalapril, metoprolol, aspirin, simvastatin, and pantoprazole. He appears ill. His temperature is 37°C (98.6°F), pulse is 131/min, respirations are 31/min, and blood pressure is 82/56 mm Hg. Pulse oximetry on room air shows an oxygen saturation of 92%. The lungs are clear to auscultation. Cardiac examination shows no abnormalities. Examination shows a painful pulsatile abdominal mass. Intravenous fluid resuscitation is begun. Which of the following is the most appropriate next step in management?

Transfusion of packed red blood cells

CT scan of the abdomen and pelvis with contrast

Supine and erect x-rays of the abdomen

A 67-year-old man presents to the emergency department with altered mental status. The patient is non-verbal at baseline, but his caretakers at the nursing home noticed he was particularly somnolent recently. The patient has a past medical history of diabetes and Alzheimer dementia. His temperature is 99.7°F (37.6°C), blood pressure is 157/98 mmHg, pulse is 150/min, respirations are 16/min, and oxygen saturation is 98% on room air. Laboratory values are obtained and shown below. Hemoglobin: 9 g/dL Hematocrit: 33% Leukocyte count: 8,500/mm^3 with normal differential Platelet count: 197,000/mm^3 Serum: Na+: 139 mEq/L Cl-: 102 mEq/L K+: 4.3 mEq/L HCO3-: 25 mEq/L BUN: 37 mg/dL Glucose: 99 mg/dL Creatinine: 2.4 mg/dL Ca2+: 12.2 mg/dL The patient has lost 20 pounds over the past month. His parathyroid hormone is within normal limits, and his urinary calcium is increased. Physical exam demonstrates discomfort when the patient's lower back and extremities are palpated. Which of the following is the most accurate diagnostic test for this patient's underlying diagnosis?

Urine, blood, and cerebrospinal fluid cultures

Surgical oncology emergencies for USMLE Step 2 CK: High-Yield Surgery Lessons

💥 Pathophysiology - Anatomic Catastrophes

Obstruction: Tumor mass physically blocks a lumen.
- GI Tract: Malignant Bowel Obstruction (MBO) from colorectal, ovarian CA.
- Biliary Tree: Obstructive jaundice from pancreatic head CA, cholangiocarcinoma.
- Urinary Tract: Hydronephrosis from cervical, prostate, bladder CA.
- Airway: Stridor, dyspnea from lung, laryngeal, thyroid CA.
Perforation: Tumor necrosis or invasion through a hollow viscus wall.
- Leads to peritonitis, sepsis.
- Common in GI lymphomas, GISTs, advanced colorectal CA.
Hemorrhage: Tumor erosion into blood vessels or bleeding from friable tumor surface.
- Presents as acute bleed (e.g., hemoptysis) or chronic anemia.

⭐ Ovarian cancer is a leading cause of malignant bowel obstruction from an extra-intestinal primary tumor, often causing diffuse peritoneal studding and multiple points of obstruction.

CT scan of malignant bowel obstruction

🚩 Clinical Manifestations - Red Flag Rundown

Emergency	Key Signs & Symptoms	Diagnostic Clues
SVC Syndrome	Facial/arm edema, plethora, JVD, dyspnea, cough, headache. 💡 Pemberton's sign (facial flushing on arm elevation).	Chest X-ray: widened mediastinum. CT chest with contrast is definitive.
MSCC	⚠️ New/worsening back pain (esp. nocturnal/supine), radicular pain, motor weakness, sensory loss, saddle anesthesia, bowel/bladder dysfunction.	MRI of the entire spine is the gold standard.
MBO	Nausea, vomiting (bilious/feculent), abdominal distention, obstipation, colicky pain. Bowel sounds: high-pitched → absent.	Abdominal X-ray: dilated loops, air-fluid levels. CT abdomen confirms level/cause.

⏱️ Diagnosis - Race Against Time

Initial Steps: Rapid ABCs assessment, focused history (cancer type, prior treatments), and targeted physical exam (neurologic, vascular).
Core Labs: CBC, CMP, coagulation panel, lactate. Consider tumor markers if relevant.

Malignant Spinal Cord Compression (MSCC):
- MRI of the entire spine is the gold standard.
Superior Vena Cava (SVC) Syndrome:
- CT chest with IV contrast to visualize obstruction.
Malignant Bowel Obstruction (MBO):
- Initial: Abdominal X-ray (air-fluid levels).
- Definitive: CT abdomen/pelvis with contrast.
Tumor Hemorrhage:
- Endoscopy, bronchoscopy, or angiography for localization.

Epidural metastasis grading on axial CT and MRI

⭐ New-onset back pain in a known cancer patient, especially with neurologic symptoms (weakness, sensory loss, incontinence), is Malignant Spinal Cord Compression until proven otherwise.

⚔️ Management - Damage Control

A staged surgical strategy for exsanguinating patients (e.g., ruptured tumor), prioritizing physiology over immediate definitive repair. The goal is to interrupt the "Lethal Triad."

Phase 1 Techniques:
- Hemorrhage: Perihepatic packing, vessel ligation/shunting.
- Contamination: Resection without anastomosis (staple off bowel).
Phase 2 Goal: Restore physiologic reserve.
Phase 3 Goal: Definitive anatomical repair and formal closure.

⭐ The "Lethal Triad" - Hypothermia (<35°C), Acidosis (pH <7.2), and Coagulopathy - is the primary indication. Each component potentiates the others, creating a vicious cycle that must be broken in the ICU.

⚡ Biggest Takeaways

Spinal cord compression: Suspect in cancer patients with new back pain/neuro deficits. Get emergent MRI and give high-dose corticosteroids.

SVC syndrome: Most often from lung cancer/lymphoma. Presents with facial/arm swelling. Treat with radiation and/or stenting.

Malignant pericardial effusion/tamponade: Diagnose with echocardiogram; treat emergently with pericardiocentesis.

Malignant bowel obstruction: Manage with NG tube decompression and consider surgical bypass or stenting.

Acute airway obstruction: Requires emergent tracheostomy or endobronchial stenting/debulking.

Massive tumor bleeding (e.g., hemoptysis): Control with angiographic embolization or surgery.

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Surgical oncology emergencies