Delayed Diagnosis of Strangulated Bowel Leads to Bowel Resection

This case involves a female patient who initially wanted to use Essure as a permanent form of contraceptive, but changed her mind and underwent a tubal ligation at a local community hospital instead. The procedure was performed by her private gynecologist and shortly after the procedure, the patient experienced a severe episode of nausea and projectile vomiting. Three days after the procedure, the patient saw her gynecologist who suspected that there was a hematoma in the lower quadrant of the abdomen. The patient was sent back to the hospital where she was admitted for a suspected small bowel obstruction. After being closely followed and treated conservatively with NG tube decompression and slow advancement of a liquid diet, the decision was made to discharge the patient after she had a bowel movement. No scans or confirmatory tests were performed upon discharge. The patient was discharged after a 10-day hospital stay despite the fact that she was continuing to feel ill. Two weeks later, the patient underwent a CT scan for complaints of abdominal pain and the imaging revealed the presence of a hernia. The patient was sent for surgery which identified a significant amount of incarcerated necrotic bowel that was resected due to strangulation.

Question(s) For Expert Witness

1. What diagnostic methods should have been employed to make an earlier diagnosis?

Expert Witness Response

The diagnosis of an incarcerated hernia is sometimes difficult, but awareness of this entity in the setting of a small bowel obstruction patients should point in this general direction and warrant a detailed examination of the abdominal region, making a prompt diagnosis possible. Additionally, ultrasound is useful in establishing the diagnosis of a hernia and color Doppler studies provide information about the viability of the herniated bowel that is important for surgical planning.