A 42-YEAR-OLD woman is admitted to the hospital complaining of epigastric pain of five days' duration, radiating to the lower quadrant and associated with nausea, vomiting, and constipation. The pain, originally severe, relents after 24 hours and then becomes generalized throughout the abdomen and is associated with chills and fever. A physician finds rigidity, tenderness, rebound tenderness, and a tender mass in the right lower quadrant; the rectal examination shows peritoneal bogginess with notable right lower quadrant tenderness.
At the time of admission the patient's temperature is 39.4 °C. She complains of chills. The skin is flushed and warm. The blood pressure (BP) is 120/80 mm Hg. A course of antibiotics is begun. Later the BP increases to 160/70 mm Hg, and the pulse rate and urinary output decrease. Then the skin becomes cold and clammy, the BP decreases to 60/0 mm Hg, and the pulse rate increases to 150