This case takes place in Kansas and involves a middle-aged male patient who died from septic shock, multiorgan dysfunction syndrome, bowel perforation, and bowel ischemia/bowel infarction. His past medical history included Roux-en-Y gastric bypass and surgery to correct scoliosis. He presented to the hospital with complaints of abdominal, low back ,and chest pain which had started after eating lunch at work. There was no associated trauma. An EKG, urinalysis, and abdominal CT scan without contrast were negative. An abdominal examination revealed a soft, nontender, nondistended abdomen. He was admitted with a differential diagnosis including kidney stone versus pyelonephritis versus musculoskeletal pain. He continued to complain of pain of 10/10 and developed nausea. He declined to eat and reported constipation. There was a change in his condition two days later, when the patient developed a temperature of 100.4, displayed an elevated white count at 12.4 (up from 8.1 when he first entered the hospital), his BUN was 74, his creatinine was 1.4, and he had 49 bands. The patient became lethargic and complained of lower back and abdominal pain. Later that morning, his white count dropped to 4.6. His abdomen became slightly distended and diffusely tender. In the early afternoon, he was hypotensive to 99/54. He had hypoactive bowel sounds and that evening his abdomen was noted to be firm, tender, and distended. He began to vomit and an NG tube was dropped.
An x-ray revealed a possible early or partial bowel obstruction. Twenty-four hours after his first elevated temperature, a CT with contrast was obtained. It revealed portal venous gas, anterior free air, pneumatoses, and diffuse punctate mesenteric free air. The findings were thought to be concerning for stercoral perforation. He was taken into the OR where he was found to have necrosis of his Roux-en-Y limb down to the terminal ileum. His entire pelvis was deeply ischemic, and he underwent a subtotal colectomy. Pathology revealed transmural infarction, and he passed away several hours after the surgery was performed. The patient had an ischemic bowel which went undiagnosed over the course of his hospitalization. He received milk of magnesia during the morning of his rapid change in condition, and he received magnesium citrate in the evening after he was noted to have hypoactive bowel sounds. It is alleged that he may have perforated his bowel after receiving these medications.
Question(s) For Expert Witness
- 1.) Do you treat patients with these presenting complaints? If so, how often?
- 2.) What is the standard work up for these patients?
- 3.) Is missed diagnosis of bowel ischemia common?
Expert Witness Response E-001188
I see a lot of complex patients at my institution both through referrals and through the ED. I would estimate I see ischemic bowel cases 6-12x per year. The work-up is pretty case specific but generally includes a CT with contrast and in the case of a patient with Roux limb often involves early diagnostic laproscopy to rule out internal hernia. Diagnosis can be missed but shouldn’t be, if correct work-up is performed.
Expert Witness Response E-008438
I have certainly treated many patients with both intestinal ischemia and colonic ischemia. I treat patients with bowel obstruction/small bowel ileus/colonic ileus/acute constipation on a near-daily basis. From your summary, it certainly seems that he probably should not have received the milk of magnesia and the magnesium citrate was absolutely contraindicated in his case (where a bowel obstruction was a concern). It sounds like he had an internal hernia from his gastric bypass surgery. These have been well described and the different types have even been named in the literature. It is always a concern when a patient presents with “pain out of proportion to physical examination” any time after having a gastric bypass/roux-en-y surgery and can cause intestinal ischemia (which this patient certainly had). This diagnosis absolutely should have been on the differential in this case. The standard workup for this patient early on would likely have been H & P, labs (including lactate), and a CT scan of the abdomen and pelvis with oral and IV contrast (which he did not receive). Delayed diagnosis of bowel ischemia isn’t uncommon because it is difficult to tell what is causing the pain, but all surgeons are aware of the risk of intestinal ischemia in a patient such as this with “pain out of proportion to physical exam,” as noted above.