Perforation of small intestine due to metastatic lung cancer
The present case has been published in BMJ. A 66-year-old woman with a history of 40 pack-year cigarette smoking and type II diabetes mellitus presented to the emergency department with unexplained weight loss and cough for a few weeks. These complaints constituted her first clinical manifestation.

Physical examination was notable for diffuse abdominal tenderness. Chest and abdominal films revealed a prominent round opaque lesion in the right lung (arrow) and a large amount of free air under diaphragms with air-fluid levels.

The patient underwent an urgent laparotomy for pneumoperitoneum. Perforation of the small intestine due to a malignant metastasis was detected. The patient underwent a wide resection of the small intestine with closed loop anastomosis.

The biopsy specimen was consistent with poorly differentiated squamous cell lung carcinoma staining positively for PDL-1 receptor. Her postoperative course was malignant, including: superior vena cava syndrome treated with a stent, redo operation due to eventration and nosocomial pneumonia, and she was transferred to an oncologic centre for palliative mediastinal radiation. The patient succumbed 6 weeks after admission

Learning points
• Peritonitis in a heavy smoker patient with unexplained ongoing weight loss may be due to intestinal perforation caused by remote metastasis.

• The prognosis of a patient with an intestinal perforation due to lung cancer metastasis is poor.

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