Commentary

An unfortunate twist


 

References

The story

FR was a 55-year-old woman who developed relatively acute and diffuse upper abdominal pain shortly after finishing dinner with friends at a local restaurant. Over the next 1-2 hours and after returning home, FR’s pain became most severe and was associated with nausea and emesis. FR contacted her daughter, who came over to assist. At approximately 10:30 p.m., FR called for an ambulance and was taken to the nearest emergency department.

On arrival at the ED, FR had a normal blood pressure and heart rate, but complained of 10/10 abdominal pain. An EKG was quickly performed and was normal. On examination, FR was noted by the ED physician as "uncooperative answering questions, rocking in bed moaning." The abdomen was documented as soft but diffusely tender to palpation in all four quadrants. A posteroanterior/lateral chest radiograph (CXR), full blood chemistries, and a complete blood cell count were obtained.

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Abdominal pain, nausea and emesis are all symptoms to watch.

The initial impression by the ED physician was biliary colic, and he also ordered a right upper quadrant ultrasound. In the meantime, FR received a "GI cocktail" (Mylanta, viscous lidocaine, and Donnatal) by mouth, along with intravenous morphine and Zofran. About 1 hour later, FR reported minimal improvement in her symptoms. The CXR, right upper quadrant ultrasound, Chem-12, lipase, and CBC all returned within normal limits.

At this point, the ED physician recommended discharge home with outpatient follow-up. The daughter, who had been with her mother all evening, became very upset and demanded that the patient be admitted because something was obviously wrong with her mother.

The ED physician called Dr. Hospitalist to admit FR for uncontrolled abdominal pain. An hour later, Dr. Hospitalist saw FR on the medical floor, by which time the daughter had left the hospital for home.

FR was lethargic from several doses of hydromorphone, but she was still complaining of severe abdominal pain. Dr. Hospitalist documented that FR had a history of hypertension, hyperlipidemia, anxiety, and depression, along with a gastric lap-band procedure 2 years ago for morbid obesity. FR’s abdomen was noted to be "reasonably soft" with hypoactive bowel sounds. The impression from Dr. Hospitalist was acute postprandial abdominal pain of unclear etiology. The plan included a routine GI consult, a routine plain film of the abdomen to look for evidence of gastric distention, keeping FR nothing per os (NPO), and continuing intravenous fluids and analgesia.

At 8:30 a.m., FR was found unresponsive and a Code Blue was called. Resuscitation efforts confirmed a profound acidemia (pH 6.55), and FR did not survive. FR was last seen by the nurses an hour earlier and had been documented as "sleeping." An autopsy was performed and discovered small bowel necrosis consistent with a small bowel volvulus.

Complaint

The daughter was shocked and upset over the sudden death of her mother. She felt that none of the medical providers took her mother’s complaints seriously because FR had a history of "anxiety." The daughter was particularly angry over the fact that the ED physician actually wanted to discharge FR in the presence of a lethal condition. She followed up with an attorney almost immediately, who had the case reviewed and subsequently filed a lawsuit.

The complaint alleged that the ED physician and Dr. Hospitalist both failed to appropriately image FR’s abdomen with either a plain abdominal radiograph and/or CT scan of the abdomen. The complaint further alleged that had they done so, the small bowel volvulus would have been discovered and successfully treated, preventing FR’s demise.

Scientific principles

Volvulus is a special form of mechanical intestinal obstruction. It results from abnormal twisting of a loop of bowel around the axis of its own mesentery and often results in ischemia or even infarction.

When it occurs in adults, volvulus usually affects the sigmoid colon or the cecum. In contrast, small bowel volvulus is relatively rare. Plain radiography and CT of the abdomen are the most practical and useful diagnostic modalities.

All patients suspected of having complicated bowel obstruction (complete obstruction, closed-loop obstruction, bowel ischemia, necrosis, or perforation) based upon clinical and radiologic examination should be taken to the operating room for abdominal exploration. Failure to identify and treat small bowel volvulus in a timely manner can lead to catastrophic results.

Complaint rebuttal and discussion

The defense in this case focused on the rarity of this condition, along with the limited time window to successfully save FR’s life. The defense argued that while FR was in the window for diagnosis and successful treatment (i.e., 10:30 p.m. until 3 a.m.), all of FR’s vital signs were normal, and her abdominal exam was inconsistent with an acute abdomen.

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