Acute abdominal pain in an elderly patient
A possible large bowel obstruction and severe dehydration prompted us to admit this patient. But a day later, the clinical picture became even more worrisome.
Surgery is the next step
Management of pneumoperitoneum includes a prompt surgical consult for a possible emergent laparotomy, nasogastric suctioning, supportive measures for blood pressure, and broad-spectrum antibiotics such as a fourth-generation penicillin or a third-generation cephalosporin plus metronidazole.10
The end of the fight
Given the high mortality rate and the atypical presentation of perforated viscus in the elderly, it is important to maintain a high index of suspicion in this population and to intervene rapidly to improve the outcome.
In the case of our patient, the family followed her wishes and declined surgery. She was aggressively managed with broad-spectrum antibiotics, IV fluids, and vasopressors—but unfortunately died 2 days later.
CORRESPONDENCE Balaji Yegneswaran, MD, University of Pittsburgh Medical Center, 651, Scaife Hall, Pittsburgh, PA 15261; byegneswaran@gmail.com
