Mr Y, a 24-year-old plumber, had suffered intermittent bouts of cramping abdominal pain with associated passage of loose stools, mucous, and occasional small amounts of fresh red blood, for two months. His GP, Dr D, referred him to Dr B, consultant gastroenterologist. Dr B saw Mr Y in clinic and arranged to carry out an outpatient colonoscopy.
Dr B managed to pass the scope as far as the splenic flexure, but was unable to progress any further due to difficult anatomy and the pain that the procedure was causing Mr Y. The colonoscopy was terminated. The appearance of the colonic mucosa up to the furthest point reached had been normal. At the time of the procedure, Mr Y’s symptoms had settled so Dr B reported the colonoscopic findings and the technical difficulties to Dr D, and discharged Mr Y back to his care.
An expert in gastroenterology felt that Dr B had done all that could be expected of him, given the well-documented technical difficulties in performing the colonoscopy, and that Mr Y was asymptomatic at the time. It was considered that in this context the risk of perforation due to over-zealous passage of an obstructed colonoscope outweighed the benefits of pressing on with the procedure.
Dr B’s letter to Dr D had clearly advised that, should Mr Y’s symptoms recur, it would be advisable to repeat the procedure or consider other forms of investigation. On this basis, we elected to defend Dr B and he was eventually dropped from the legal action. The case was settled out of court for a moderate sum on behalf of Dr D.
If diagnostic investigations have to be curtailed for technical reasons, best practice dictates that clear reasons for abandoning the procedure should be documented in the medical record.
It is important to consider whether alternative investigations or a repeat attempt are necessary after having to abandon an investigation. In this situation, the patient was asymptomatic, but in such a scenario, advice to the referring doctor on what to do if the problem recurs is essential.
General practitioners should have a low threshold for asking for further advice where there is an inconclusive or abandoned specialist investigation, and ongoing or worsening symptoms.
Coriat R et al., Quality Control of Colonoscopy Procedures: A Prospective Validated Method for the Evaluation of Professional Practices Applicable to all Endoscopic Units, Gastroenterol Clin Biol Sep. (2008); Epub ahead of print. Available via www.pubmed.gov