Child Dies From Bowel Necrosis After Failure to Diagnose Volvulus

This case involves an eight-year-old female patient who presented to the ER with a two-day history of severe abdominal pain. She had a past medical history significant for developmental delay and difficulties feeding. The patient underwent surgery to place a feeding tube several months prior to presentation. The patient was examined in the ER and admitted for observation. Abdominal x-rays were ordered but the interpretation of imaging at this time was abdominal pain due to constipation and the patient was discharged shortly thereafter. No CT scan was performed. The following day the patient returned to the hospital with increasing pain and it was at this time that a pediatric emergency medicine physician ordered a CT scan. The repeat abdominal imaging studies revealed a dilated intestine with possible perforation. The patient was brought into surgery urgently and a volvulus was discovered to be the cause of the patient’s pain. According to the medical records, the patient experienced a prolonged lack of blood supply to the abdominal viscera and subsequently sustained a significant amount of bowel necrosis by the time she finally went to surgery. The patient could not be weaned off of the ventilator post-operatively and the family decided to withdraw life support shortly thereafter.

Question(s) For Expert Witness

1. Would the CT scan have revealed the volvulus immediately and would this have made a difference in the outcome of the surgery had it been performed sooner?

Expert Witness Response E-005297

The issue is really not whether the CT would have revealed a volvulus. The CT would show the abnormality and if there was contrast included, likely show edema and/or perforation. However, the real question will be whether the CT was indicated at the first presentation to the physician. In pediatrics, we are concerned about cumulative radiation exposure to the patient. In this scenario, I suspect that with developmental delay and the surgical procedures that she underwent, the child already has had significant imaging in the past. They key will be to review the subjective presentation (symptoms, similar to before?), objective data (elevated white count, CRP etc), and clinical response. If this information reveals a clinical picture indicative of bowel pathology it may be deemed a departure from the standard of care to not have ordered more rigorous imaging.