Blunted Peritoneal Signs in an Elderly Patient with Ruptured Appendicitis and Periappendiceal Abscess
Blunted Peritoneal Signs in an Elderly Patient with Ruptured Appendicitis and Periappendiceal Abscess - Gastroenterology clinical simulation case. An...
An 84-year-old woman with three days of vague anorexia, low-grade fever, and progressive abdominal distension, presenting with subtle, nonlocalized abdominal discomfort and a hidden ruptured appendicitis with periappendiceal abscess. Margaret Whitfield is an 84-year-old retired librarian who lives alone in a single-story home. She is normally active, manages her own groceries, gardens daily, and has no significant prior abdominal surgical history. Her past medical history includes well-controlled hypertension on amlodipine 5 mg daily, mild osteoarthritis of the knees, and age-appropriate early cataracts. She has no documented history of inflammatory bowel disease, no prior appendectomy, and her last colonoscopy five years ago was unremarkable. She is fully vaccinated including pneumococcal and influenza. Her daughter, Karen, lives 40 minutes away and checks on her every other day. Margaret is a fiercely independent woman who is somewhat stoic and dislikes 'making a fuss' about her health. Cognitively, she is sharp, oriented, and able to give a coherent history.
Acute Resuscitation Milestones & Priorities
Clinical phases and key interventions encountered in this emergency module:
Initial Resuscitation Bay Evaluation & Recognition of Atypical Presentation
Imaging, Source Confirmation, and Differential Refinement
Sepsis Escalation, Hemodynamic Optimization, and Source-Control Decision
Operative Source Control, Definitive Disposition, and Postoperative Sepsis Trajectory
High-Yield Clinical Pearls
In elderly patients, appendicitis frequently presents with vague constitutional symptoms (anorexia, low-grade fever, malaise, altered mental status) rather than classic RLQ pain. Absence of peritoneal signs does not exclude surgical pathology.
Contrast-enhanced CT abdomen/pelvis is the diagnostic modality of choice for suspected appendicitis in non-pregnant adults of any age. Point-of-care ultrasound is acceptable as a first-line screen but should not delay definitive imaging when clinical suspicion persists.
Geriatric sepsis is dominated by cryptic shock: lactate elevation and end-organ trends (creatinine, urine output, mentation) often precede overt hypotension. Do not wait for BP to crash before initiating the sepsis bundle.
Empiric antibiotics in intra-abdominal sepsis with hemodynamic instability should cover gram-negatives (including Pseudomonas), gram-positives, and anaerobes. Piperacillin-tazobactam monotherapy is guideline-preferred over ceftriaxone/metronidazole in this population.
Source control is the dominant prognostic intervention. Delay-to-source-control is independently associated with mortality. In a deteriorating septic patient, do not delay the OR for 'optimization.'
Frailty assessment—not chronological age—should drive goals-of-care discussions postoperatively. Many patients >80 recover well after timely appendectomy when source control is achieved.
Antimicrobial de-escalation based on intraoperative cultures should occur within 48-72 hours when the patient is clinically improving, to reduce multidrug-resistant organism selection and Clostridioides difficile risk.
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