© Cambridge University Press 2015. History of present illness: A 64-year-old white woman with stage IIIC ovarian cancer presents to the emergency room with the chief complaint of abdominal pain. She reports acute onset of moderate-to-severe diffuse abdominal pain as well as progressive nausea and vomiting over the past three days. The emesis is nonbloody but bilious. The patient reports that she has not been able to tolerate any oral intake, including fluids or anti-emetics, for the past 24 hours. Her last bowel movement four days ago was loose and watery, although she reports flatus. She was diagnosed with ovarian cancer one year ago and was treated with complete surgical cytoreduction followed by six cycles of platinum- and taxane-based chemotherapy. Her medical history is otherwise unremarkable, and her surgical history is significant for a laparoscopic cholecystectomy as well as a complete hysterectomy and staging procedure as above. She was recently seen in clinic and was noted to have a rising CA-125 and underwent a CT scan that demonstrated recurrence with diffuse intrabdominal disease including peritoneal implants. Physical examination General appearance: Well-dressed thin woman in mild distress Vital signs: Temperature: 37.0°C Pulse: 116 beats/min Blood pressure: 108/61 mmHg Respiratory rate: 22 breaths/min Oxygen saturation: 99% on room air HEENT: Dry mucous membranes Cardiovascular: Regular rhythm, tachycardia, no murmurs, rubs, or gallops Pulmonary: Symmetric chest expansion, clear to auscultation bilaterally Abdomen: Well-healed midline scar; high-pitched bowel sounds heard in bilateral upper quadrants; moderately distended abdomen tympanic to percussion with mild tenderness diffusely; no palpable masses; no rebound or guarding Genitourinary: Normal external female genitalia; bimanual examination reveals an intact vaginal cuff; no adnexal masses; cervix is surgically absent Rectal: Normal sphincter tone, hemoccult negative, no masses palpated Neurologic: Alert and oriented × 4.