Undifferentiated shock in the elderly: Hemorrhagic shock from a bleeding epiploic appendage varix

Undifferentiated hypotension with altered mental status in elderly patients poses a diagnostic challenge in the emergency department. Although fluid resuscitation may yield transient hemodynamic improvement, this response can obscure life-threatening pathology. Rarely, bleeding from an epiploic appendage can cause intra-abdominal hemorrhage and lead to sudden hemodynamic collapse. An 83-year-old male presented with acute altered mentation and hypotension. He received two liters of intravenous fluids with a transient improvement in symptoms. Broad-spectrum antibiotics were initiated for possible sepsis, and admission was planned. Hours later, while awaiting transfer, he developed worsening hypotension and new onset abdominal distension. Laboratory testing revealed a hemoglobin decline from 11.5 g/dL to 5.0 g/dL. Emergent imaging demonstrated free intraperitoneal air and hemoperitoneum. A massive transfusion protocol was activated, and the patient required intubation and vasopressor support. Emergency laparotomy identified a bleeding epiploic appendage with significant hemoperitoneum, which was surgically managed. Why Should an Emergency Physician Be Aware of This?: This case highlights how a transient improvement in shock can mask intra-abdominal hemorrhage. Emergency physicians should maintain a broad differential in elderly patients with undifferentiated hypotension, reassess frequently after initial stabilization, and consider uncommon but life-threatening etiologies when abrupt decompensation occurs.