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A delayed diagnosis

01 January 2014

Miss O, a 22-year-old woman, was admitted as a medical emergency with vague abdominal pain and urinary frequency. Clinical examination revealed a right iliac fossa scar from an appendicectomy three years earlier and some mild supra-pubic tenderness.

Her white cell count was elevated, she had a low grade temperature and urinalysis demonstrated blood and leucocytes. A chest and abdominal radiograph at this stage appeared normal. A provisional diagnosis of a urinary tract infection was made and Miss O was commenced on intravenous antibiotics.

Forty-eight hours later, the situation had deteriorated and Miss O now had worsening abdominal pain, nausea and a persistent pyrexia. Overnight, she was reviewed by the resident surgical officer who found a distended abdomen with localised guarding in the right iliac fossa. He advised keeping the patient ‘nil by mouth’ and prescribed intravenous fluids and analgesia. A further abdominal radiograph was requested, a nasogastric tube and urinary catheter were inserted, and the patient was transferred to a surgical ward.

General surgeon Mr S reviewed the patient the following morning and requested an ultrasound scan. This demonstrated the presence of dilated small bowel loops with bilateral pleural effusions and free fluid in the peritoneal cavity. When he saw the patient 24 hours later, she remained unwell; review of the abdominal x-ray from 36 hours earlier confirmed the ultrasound suggestion of small bowel obstruction.

Mr S concluded that it was likely a consequence of adhesions from her previous appendicectomy and, later that day, he undertook a laparotomy. This revealed small bowel obstruction secondary to a band adhesion. After division of the band and decompression of the small bowel, a 10cm section of ileum required resection and anastomosis.

Initially, Miss O improved and began oral intake and mobilisation. However, on day three following her surgery, she complained of cramp-like abdominal pain and a productive cough. Miss O had mild abdominal distension and absent bowel sounds. Further x-rays revealed left lower lobe collapse and consolidation and some ongoing dilated small bowel loops. She was reviewed by Mr G, locum general surgeon, as Mr S was on annual leave for three weeks. A diagnosis of pneumonia and ileus was made and intravenous antibiotics were prescribed.

A further period of prolonged nasogastric drainage and parenteral nutrition then ensued. The ‘ileus’ failed to resolve and a gastro-graffin small bowel study showed delayed passage of contrast through dilated small bowel loops consistent with a low grade obstruction. Mr G recommended further surgery but Miss O and her family were reluctant and wished to persevere with conservative management.

When Mr S returned from annual leave, Miss O was still obstructed and by this stage all were in agreement that further surgery was required. A second difficult laparotomy and division of adhesions was undertaken, revealing an area of possible Crohns stricture at the anastomosis which was resected and re-anastomosed.

Miss O required treatment on the intensive care unit and then developed a severe wound infection and entero-cutaneous fistula. She spent several months in hospital and eventually was discharged with persistent intermittent abdominal pain and altered bowel habit. There was no evidence of inflammatory bowel disease.

Miss O brought a claim against Mr S, citing a delay in the diagnosis and treatment of her small bowel obstruction as the cause for her further surgery, prolonged hospital stay, and subsequent intestinal complications and ongoing symptoms.

Expert opinions were critical of the delay in making the diagnosis of small bowel obstruction and undertaking surgery. They felt that an ultrasound examination had been unnecessary and that Mr S should have reviewed the abdominal x-ray (which clearly showed evidence of obstruction) when he initially reviewed the patient and not the following day. Had he seen the film, the finding of peritonism three days into her illness may have prompted Mr S to perform earlier surgery, before the small bowel ischaemia had become irreversible.

The case was settled for a moderate sum.

Learning points

  • The results of investigations should be reviewed promptly and acted upon accordingly. Generally, adhesional small bowel obstruction requires surgical intervention if, after appropriate conservative treatment, there is no sign of clinical improvement.
  • Medicolegal problems often arise long after the clinical encounter. Considerable discussion regarding this case centred upon documentation of when patient reviews occurred and when Miss O’s x-ray investigations were assessed. Accurate and legible entries into the notes (even down to the hour) are the cornerstone to any medicolegal defence.