Delayed diagnosis of mid-gut volvulus turns fatal

This case involves a twenty-one year-old female patient with a past medical history of asthma and juvenile arthritis. The patient presented to the emergency room of a local hospital with complaints of acute mid-gut pain, nausea and vomiting. The patient complained of severe abdominal pain which she rated as 9 out of 10 on the pain scale. The patient had arrived at the hospital at 3.00 AM. The patient was not taken for abdominal imaging studies until approximately 5:15 AM at which point X-rays indicated that there was an early partial bowel obstruction. It also indicates that there is a substantial gas in the mid-gut suggesting a volvulus. The patient was taken back to the ER and had to wait in excruciating pain until 10:15 AM for additional CT scan studies. The abdominal CT scans revealed evidence of bowel stasis. The radiologist also voiced concerns due to the appearance of a swirl pattern of the interior aritic region suggesting focal vascular volvulus. This information was communicated to the ER staff at 10:30 AM. The ER staff reported in the patient’s medical notes that there would be a surgical consult at 3 PM that day. The patient was finally taken into surgery several hours later. In the operating room the treating surgeons found extensive areas of necrotic bowel. The patient had almost four feet of intestines and a large portion of the ascending colon surgically removed in an effort to save her life. The patient’s abdomen was left open for subsequent surgeries as she was air lifted to a tertiary hospital specializing in general surgery but unfortunately she passed away a few weeks later.

Question(s) For Expert Witness

Do you have experience in this type of bowel obstruction and can you explain the time sensitive nature of the surgery?

Expert Witness Response E-000211

As a board-certified general surgeon I frequently take trauma call. I also frequently see and operate on thses patients. I have testified successfully in delayed diagnosis of mid-gut volvulus cases in the past. In the case of volvulus, the time it takes to decompress the bowel is extremely important. Bowel obstruction should immediately be decompressed to minimize this specific complication of bowel strangulation and necrosis. This is an absurd imaging delay. The patient’s clinical history warranted immediate investigation. Furthermore, swirl sign (rotation around superior mesenteric artery) is a surgical emergency. Delay in surgery undoubtedly led to bowel demise. Had the patient received an intervention sooner the outcome would have been considerably better.