Mr K, a builder in his thirties, started to suffer from bouts of abdominal pain. He was seen by Dr B, general-surgical specialist, who noted a history of paroxysmal epigastric and lower-abdominal pain, weight loss, anorexia and mild anaemia. Dr B considered a diagnosis of pancreatitis.
A CT scan of the upper abdomen was reported as normal without evidence of pancreatitis. Mr K was discharged then readmitted with persisting symptoms. He was given analgesia; small bowel contrast studies were normal. Mr K was discharged again.
The next month he came back after losing further weight and suffering more pain and regurgitation of food. He was informed by Dr B that he had found no evidence of a pathological cause for his symptoms and that they were a product of his mind. Dr B discontinued Mr K’s analgesia and discharged him.
Mr K struggled on, consulting a doctor in a nearby town a month later. A CT scan of the whole abdomen showed hepatosplenomegaly with associated para-aortic lymphadenopathy and lobulated masses around the head of the pancreas.
At laparotomy a terminal ileal tumour was found with extensive mesenteric lymphadenopathy and a diagnosis of B-cell non-Hodgkin’s lymphoma was made. Mr K underwent chemotherapy and radiotherapy. He did well with an estimated 43% chance of five-year survival.
Mr K sued Dr B and the radiologist who had reported his initial CT scan and small bowel studies. He alleged that insufficient investigations had been conducted to assess the cause of his symptoms and anaemia, and that a lower abdominal CT scan should have been done. He alleged that this would have enabled earlier diagnosis and treatment of his lymphoma, giving him a more favourable prognosis.
A gastroenterology expert considered that Dr B had appropriately assessed and investigated Mr K’s abdominal pain. The expert concluded that on the information available to Dr B at the time, there was no evidence to suggest a physical cause for Mr K’s symptoms. It may well have been impossible to pick up signs of an early, rapidly growing lymphoma.
However, it was noted that there had been no focus on finding a cause for Mr K’s anaemia; indeed there was very little useful documentation about this clinical fact in his notes.
A radiology expert examined Mr K’s small bowel imaging and found no evidence of any abnormality of the terminal ileum. Another radiologist looked at Mr K’s initial CT scan. There were some small cystic masses noted in the mesenteric root, encasing mesenteric vessels. There were also 1cm hypodense nodules adjacent to the duodenojejunal flexure and superior mesenteric vessels. A cystic adenopathy of uncertain aetiology was suggested by the scan.
We settled the case because Dr B had failed to investigate Mr K’s anaemia, a point on which he was vulnerable to criticism. The fact that the initial CT scan did not include the whole abdomen and may have missed subtle evidence of lymphadenopathy were other issues where it may have proved difficult to defend Dr B and his radiological colleague.
- Clinical information - Where the diagnosis is uncertain, it is important to integrate and fully consider all clues as to the cause of an illness. In the face of continuing significant physical symptoms, it is unwise to ascribe a psychological cause without ensuring that all likely or feasible alternative diagnostic hypotheses have been exhausted. Sometimes a psychological, psychiatric or other specialist opinion will need to be sought before making this conclusion. A patient who has wrongly had a physical illness attributed to a psychological cause may be more likely to complain or take legal action. The most important determining factor as to how thoroughly and urgently to seek a cause for symptoms is the state of the patient, not the investigations.
- Anaemia and non-Hodgkin’s lymphoma - Unexplained anaemia is a portent of serious illness until proven otherwise. The British Society of Gastroenterology has published some guidelines on the general investigation of anaemia, which are available on their website, www.bsg.org.uk
A useful and extensive international glossary of guidelines, advice and statements on anaemia can be found by searching the website of the Geneva Foundation for Medical Education and Research www.gfmer.ch/, on non-Hodgkin’s lymphoma can be found in this eMedicine article, www.emedicine.com/med/topic1363.htm