Perforated Diverticulitis in a Frail Elderly Patient
A 79-year-old man from a care home is brought in with 2 days of abdominal pain, distension, and fever. He has dementia, hypertension, and CKD stage 3 with eGFR 42 mL/min/1.73 m², and he takes aspirin. BP 92/54 mmHg, pulse 118/min, respiratory rate 24/min, SpO2 94% on room air, temperature 38.9°C. The abdomen is distended and rigid with generalized peritonitis. Lactate 4.8 mmol/L, WBC 18 × 10⁹/L, creatinine 180 µmol/L. CT shows pneumoperitoneum and a sigmoid perforation with fecal contamination; there is no visible metastatic disease. The family says he is 'not for heroics' but there is no written advance directive. The surgeon on call is alone and the operating room is available. The family asks whether surgery is worthwhile.
1. How would you assess severity and decide between immediate surgery and conservative management?
Read the worked answer
This is septic shock from a perforated viscus with generalized peritonitis, lactate 4.8 mmol/L, and acute kidney injury. Conservative management with antibiotics alone has a high mortality in fecal contamination and cannot achieve source control. I would resuscitate with crystalloid, start broad-spectrum antibiotics, and involve critical care immediately. The judgement is not whether he is frail-he clearly is-but whether surgery offers a realistic chance of survival with acceptable suffering. Dementia alone is not a contraindication. Because there is no written directive, I would ask the family what he valued and whether he previously expressed wishes about major surgery. If he is potentially reversible and the family agrees, I would proceed urgently; if he is moribund with no response to resuscitation and the family confirms a palliative goal, I would provide comfort care. The default should not be 'do everything' or 'do nothing' without that discussion.
2. What operative strategy would you choose and why?
Read the worked answer
I would choose a damage-control approach: limited laparotomy, resection of the perforated sigmoid, and end colostomy (Hartmann procedure), with abdominal lavage and temporary closure. Primary anastomosis is attractive in stable patients with minimal contamination, but here fecal contamination, hypotension, renal impairment, and comorbidity make anastomotic leak dangerous. Laparoscopic lavage alone is inadequate for a free perforation with fecal peritonitis. The reasoning is to achieve source control with the shortest possible operation and lowest leak risk. I would avoid a stoma reversal discussion at this stage and document that it is a future decision. If the patient deteriorates intraoperatively, I would abbreviate the operation and leave the abdomen open for relook. The family should understand that the stoma is temporary in principle but may be permanent, and that the goal is survival, not anatomical restoration.
3. What antibiotics and perioperative measures would you choose? How would you discuss this with the family?
Read the worked answer
I would start piperacillin-tazobactam or a carbapenem, cover anaerobes, and adjust to renal function; if he is in shock, give the first dose immediately after cultures. I would give fluids, use vasopressors if needed, monitor urine output, and hold aspirin perioperatively after weighing bleeding risk. VTE prophylaxis with compression devices and early mobilization should be planned. For the family, I would use plain language: 'He has a hole in the bowel and pus in the abdomen; without an operation to remove the damaged segment and clean the abdomen, he will almost certainly die. With an operation, he may survive but will need a stoma and intensive care, and he may not return to his previous state.' I would ask about his prior wishes and document the discussion. The judgement is to present surgery as a chance, not a guarantee, and to align the plan with the family's understanding of his values.