Perforated appendicitis in the setting of a massive ventral hernia, morbid obesity, and multiple severe comorbidities: challenges in acute management
Bibliographic record
Abstract
Case summary A 57-year-old woman with morbid obesity (body mass index [BMI] of 43), systemic lupus on steroids, type 2 insulin-dependent diabetes, peripheral vascular disease, unprovoked pulmonary embolism on rivaroxaban, and hypertension presented with 3 days of worsening abdominal pain and nausea. She had an extensive surgical history including a cesarean section, multiple laparotomies for small bowel obstructions (one complicated by bowel perforation requiring resection), and a double-barrelled ileostomy, which had been since reversed. As a result, she had a massive incisional hernia (figure 1). On presentation she was afebrile but tachycardic at 110 beats per minute. Physical examination revealed tenderness to deep palpation in the right upper and lower quadrants. CT demonstrated an 11 mm appendix with an appendicolith outside the hernia sac abutting the right kidney, discontinuity of the appendix tip, free fluid, and associated stranding in the subhepatic region (figure 2A). She was admitted to the surgical floor for a trial of conservative management with ancef and flagyl. On day 3, her pain worsened, her white cell count remained stable at 12 x109/L, her temperature was 37.8°C, she was not tachycardic, and a repeat CT showed a 15 mm perforated appendix with increased periappendiceal stranding and an associated small volume of free fluid. There was no phlegmon or organized abscess (figure 2B). Figure 1 Patient’s abdomen demonstrating midline laparotomy incisional scar, previous ileostomy scar, and massive ventral hernia. Figure 2 Abdominal CT showing increased stranding centered around the appendix, with discontinuity of the wall of the appendix tip and free fluid within the abdomen and pelvis. (A) Admission CT. White arrow: appendix. (B) CT on postadmit day 3 as patient worsened clinically. Black arrow: fecalith. What would you do? Continue non-operative management with broadened intravenous antibiotic coverage and bowel rest. Laparoscopic ± open appendectomy without concomitant hernia repair. Laparoscopic ± open appendectomy with abdominal wall reconstruction.
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How this classification was reachedexpand
Full frame machine prediction
Teacher imitationNot calibrated prevalence, not ground truth. Human validation pending. The Gemma side is a direct model label for every work in the frame, read from the title-only record. The Codex side is a classifier learned from the 10,348 direct Codex labels and calibrated to design-weighted sample rates; fields without enough sample support carry no Codex call. Candidate is the union of the two sides; consensus is their intersection. These outputs are machine_predicted_unvalidated and are not human labels.
Distilled classifier scores by category (both heads)
| Category | Codex | Gemma |
|---|---|---|
| Metaresearch | 0.002 | 0.007 |
| Meta-epidemiology (narrow) | 0.002 | 0.001 |
| Meta-epidemiology (broad) | 0.002 | 0.001 |
| Bibliometrics | 0.002 | 0.001 |
| Science and technology studies | 0.002 | 0.002 |
| Scholarly communication | 0.004 | 0.004 |
| Open science | 0.001 | 0.002 |
| Research integrity | 0.006 | 0.006 |
| Insufficient payload (model declined to judge) | 0.002 | 0.001 |
Machine scores (provisional)
The two teacher heads of the student model, read on this work. A score orders the frame for review; it never asserts a category, and the validation status ships verbatim with every row.
Baseline scores from an immature model (maturity gate not passed, 7 training rounds). Scores rank; they never assert a category.
score_only:v0-immature-baseline · verbatim from the scoring run: score_only means the number may rank works, and no category label ships from itClassification
machine, unvalidatedMachine predicted; a candidate call from one source (direct Gemma or distilled Codex), not a consensus.
How this classification was reached, model by model and score by score, is at the end of the page under "How this classification was reached".