What are the risks of discharging a patient with a perforated appendix against medical advice?

Risks of Discharge Against Medical Advice for Perforated Appendicitis

Discharging a patient with perforated appendicitis against medical advice carries significant mortality and morbidity risks, including progression to severe sepsis, septic shock, and death due to untreated intra-abdominal infection. 1

Major Risks of Untreated Perforated Appendicitis

Infection Complications

• Untreated perforated appendicitis leads to peritonitis (localized or generalized) with high risk of progression to severe sepsis and septic shock 1
• Intra-abdominal abscess formation occurs frequently without proper surgical intervention and antibiotic therapy 1
• Retroperitoneal abscess formation is a rare but serious complication with mortality rates of approximately 16.7% 2
• Polymicrobial infections from intestinal flora spread throughout the peritoneal cavity, requiring broad-spectrum antibiotic coverage 1

Systemic Complications

• Progressive organ dysfunction affecting multiple systems (respiratory, cardiovascular, renal) 1
• Septic shock with hypotension, myocardial depression, and coagulopathy requiring intensive care management 1
• Increased 30-day mortality rates compared to patients who receive timely treatment 3
• Potential for necrotizing fasciitis of the abdominal wall, a rare but potentially fatal complication 4

Extension to Adjacent Structures

• Perforation of surrounding structures (such as bladder perforation) has been reported 4
• Formation of fistulas between bowel and other organs 1
• Abscess extension to psoas muscle, perinephric space, or lateral abdominal wall 2

Standard Management of Perforated Appendicitis

Surgical Intervention

• Appendectomy (open or laparoscopic) remains the standard of care for perforated appendicitis 1
• Surgical source control is critical to prevent ongoing contamination and reduce mortality 1
• In selected cases with localized abscess or phlegmon, initial non-operative management with antibiotics and possible percutaneous drainage may be considered, followed by interval appendectomy 1, 5

Antibiotic Therapy

• Broad-spectrum antibiotics effective against enteric gram-negative organisms and anaerobes are essential 1
• Common regimens include ampicillin, clindamycin (or metronidazole), and gentamicin; or alternatives such as piperacillin-tazobactam or ticarcillin-clavulanate 1
• Antibiotic therapy alone is insufficient for perforated appendicitis without source control 1

Supportive Care

• Intravenous fluid resuscitation to maintain adequate tissue perfusion 1
• Possible need for vasopressor support in cases of septic shock 1
• Pain management and nutritional support during recovery 1

Outcomes Without Proper Treatment

Hospital Length of Stay and Costs

• Untreated perforated appendicitis typically requires significantly longer hospitalization when eventually treated 6, 3
• Average hospital stay for complicated appendicitis with retroperitoneal involvement can reach 27.3 days for survivors 2
• Increased healthcare costs due to complications requiring additional interventions 6

Long-term Complications

• Increased risk of adhesive small bowel obstruction 1
• Chronic abdominal pain and functional gastrointestinal disorders 1
• Potential for chronic wound complications if surgical site infections develop 1

Special Considerations

Pediatric Patients

• Children with perforated appendicitis have high risk of complications if left untreated 1
• Untreated infection may lead to growth and developmental issues due to prolonged illness 1
• Pediatric patients may deteriorate more rapidly than adults due to smaller physiologic reserve 1

Elderly Patients

• Higher mortality risk in elderly patients with perforated appendicitis 2
• Comorbidities in elderly patients compound the risks of untreated intra-abdominal sepsis 1
• Atypical presentation in elderly may lead to delayed diagnosis and treatment, further increasing risks 2

Conclusion for Clinical Practice

• Patients considering discharge against medical advice should be clearly informed about the high risk of mortality and severe morbidity 1
• Documentation of risks discussed is essential, including specific complications of sepsis, organ failure, and death 1
• If discharge is unavoidable, providing prescriptions for oral antibiotics (though suboptimal) and clear return instructions may mitigate some risk 1