Appendicitis Patient Develops Short Gut Syndrome Following Delayed Surgical Intervention

This case takes place in New York and involves a 35-year-old female patient with a history of ruptured appendicitis who presented with vomiting, diarrhea, and abdominal pain. A CT with contrast showed dilated loops of the small bowel. Observation management was done without a nasogastric tube. A repeat CT scan showed worsening dilation of the small bowel and an exploratory laparoscopy was conducted. The patient was discharged 2 days later despite continued nausea and vomiting. However, the patient returned to the emergency room on the same day with persistent vomiting. A subsequent CT was again suggestive of a small bowel obstruction. The patient underwent a small bowel follow-through followed by exploratory lap. During the procedure, the surgeons had to resect virtually all of the small bowel. The patient subsequently suffered from significant damages related to short gut syndrome, including daily diarrhea, constipation, a requirement of 15,000 calories per day to maintain weight, decreased immunities, and significant weight loss. The patient also suffered periodic inability to work, as she was a sales professional who frequently traveled for business. An expert in general surgery was sought to review the matter and address any lapses in the standard of care which could have led to this outcome.

Question(s) For Expert Witness

1. What is the care and treatment available to a young patient under these conditions?

2. How does losing several feet of small bowel affect life expectancy?

3. When is it safe to discharge a patient with an SBO?

Expert Witness Response E-075323

Short Gut Syndrome is managed with balanced nutrition, fluids, vitamins, minerals, and electrolytes. Occasionally, because of malabsorption, patients are required to be on Total Parenteral Nutrition. Proton pump inhibitors are often given along with a new hormone called Teduglutide that increases growth of small bowel. Over time, the small bowel may compensate to accommodate for the malabsorption, but that is unpredictable. Life expectancy depends on many factors in short gut syndrome, including the level of the patient's remaining small bowel, colon compensation for lost small bowel, an intact colon providing necessary carbohydrate salvage of nutrients, as well as fluids and electrolytes. Furthermore, monitoring and staying on top of developing deficiencies is essential, and if chronic malnutrition continues, it could have devastating effect to multiple organs, thus resulting in a significant decrease in life expectancy. Patients are followed post-operatively by bedside clinical exam, and it is safe to discharge once a follow-up of imaging studies is administered. Additionally, the patient must have a tolerance of a liquid diet initially, followed by a solid diet. I have reviewed cases of post-op ilius complications due to patients not being monitored in the hospital carefully and appropriately, a few of which have resulted in perforation and bowel necrosis. I'd be happy to help with this case.