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A male in his mid-40s with stage IV colon cancer, metastatic to the liver, peritoneum and lungs presented to the emergency department with nausea, vomiting, generalised abdominal pain and significant abdominal distension. He had undergone resection of the mass in the descending colon and was undergoing chemotherapy, with his last dose administered 2 weeks prior to presentation. His other medical history included chronic pain, depression and a pulmonary embolism for which he was on apixaban. On examination, the patient had stable vital signs but exhibited a markedly distended abdomen, minimal bowel sounds and no peritoneal signs. A CT of the abdomen ( figure 1) revealed a distended colon proximal to the colorectal anastomosis, consistent with a malignant colonic obstruction. CT further demonstrated disease progression, including increased abdominopelvic implants, enlarging liver metastases and moderate ascites. A follow-up abdominal radiograph (figure 2) in 12 hours revealed worsening dilatation of the colon up to 12 cm, with no evidence of gastric or small bowel dilation.