The acute abdomen in a patient with cancer requires the surgeon to think along a broad differential with special attention to triage and the larger context of the patient’s wishes, prognosis, and goals of care. Abdominal pain in the cancer patient may also be from diseases common to the general population including appendicitis, diverticulitis, or cholecystitis. Pain may be due to cancer or therapy-specific complications such as obstruction secondary to a malignant mass or radiation-induced stricture, perforation secondary to tumor necrosis or chronic distal obstruction, ischemia, or infection. Ultimately, the surgeon is tasked with properly diagnosing the disease entity in a timely fashion and directing therapy in conjunction with the medical and radiation oncologists considering the patient life expectancy, wishes, and quality of life. It is always indicated to discuss the patient and family wishes when establishing care or initiating aggressive medical or surgical treatments, rather than waiting to deal with major decisions only in presence of a life-threatening emergency.