Allegation: Failure to diagnose abdominal pathology on CT scan leads to ischemic bowel and ultimately multiple organ transplants.
The Case:
Failure to diagnose can have significant implications in the defense of a lawsuit, as is demonstrated in this closed claim involving a radiologist who failed to diagnose abdominal pathology on CT scan.
A 33 YOM arrived via ambulance at the medical center emergency department. He had a history of ulcerative colitis, an appendectomy two months prior, cholecystectomy, and a cadaveric liver transplant 16 years prior due to primary sclerosing cholangitis (PSC). He also underwent recent treatment for recurrent PSC and an appendectomy. He complained of severe 10 out of 10 pain, describing it as unlike anything he had experienced before.
A CT scan of the abdomen and pelvis with contrast was ordered. The Radiologist charted history of ulcerative colitis. He documented the wet read as splenomegaly, prominent vascular collaterals, obstipation, and small fluid collection of the right pelvis. He reported fatty changes of the liver, the spleen as moderately enlarged, and prominent vascular collaterals of the upper abdomen presumably related to portal hypertension. He noted that the pancreas, kidneys, stomach, and small bowel imaged normally, and further noted a large fecal load of the colon and mild thickening of the colon wall. He also documented a small collection of fluid surrounding the cecum and loops of distal ileum, and no pneumobilia of the intrahepatic biliary ductal system. The patient was discharged home with a diagnosis of likely ulcerative colitis flare-up.
Later that same evening, the patient presented to a second hospital emergency department. An additional CT scan showed twisting of the mesentery with thickened small bowel loops and associated small bowel obstruction, edema of the mesenteric root, and abdominal and pelvic swelling. Early the following morning, an emergency laparotomy revealed multiple loops of small bowel in advanced stages of ischemia, with obstruction from adhesions in the upper right quadrant. After releasing the adhesions, the small bowel was found to be irreversibly ischemic.
Subsequently, the patient underwent a transplant of the liver, small bowel, and colon for end-stage liver disease secondary to recurrent PSC, induced liver cirrhosis, short gut syndrome, TPN dependence, portal hypertension, and ulcerative colitis. The liability in this case was attributed to the failure to identify thick-walled portions of the bowel on the CT report and the abnormality of the small bowel.
Expert Testimony
All six plaintiff’s experts’ testimony suggested the Radiologist focused on the plaintiff’s previous diagnosis of ulcerative colitis, and that the failure to identify mesenteric congestion, dilated and thick-walled segments of the small bowel, and a missed diagnosis of closed-loop obstruction all contributed to the poor outcome. Further, they believed that earlier identification and intervention could have prevented the need for extensive bowel removal and transplants.
Defense experts opined that there was no small bowel obstruction, abnormal bowel dilation, or thickening at the time of the initial CT scan. They argued that the condition developed later in the night after the patient presented at the second emergency department. The defense experts believed that the initial CT scan did not warrant further explanation or urgent abdominal surgery.
Resolution
The case was settled.
Risk Reduction Strategies
Consider the following strategies to help ensure a thorough diagnostic process:
- Establish systems that enable clear and thorough communication between healthcare providers, especially when a patient with a known medical history presents with new symptoms.
- Encourage consults with colleagues, especially in cases where the interpretation is challenging or when there is a discrepancy between the imaging findings and the patient's clinical presentation.
- Provide ongoing education and training for radiologists on the importance of maintaining a broad differential diagnosis.
- Consider rare or unexpected conditions to ensure a thorough process, even when a patient's history suggests a more common diagnosis.
- Use additional support tools, such as checklists, peer review systems, structured reporting templates, or technological assistance systems to help avoid cognitive bias.
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