Missed Diagnosis of Intestinal Volvulus Causes Bowel Necrosis

This case involves a seven-year-old female who presented to the ER with abdominal pain. She had a medical history significant for developmental delay and, several months prior, required the placement of an intravenous total parenteral nutrition feeding tube (TPN). The patient was admitted for observation and x-rays were ordered, but the interpretation of imaging was abdominal pain due to constipation and the patient was discharged. The following day, the patient returned to the hospital with increasing pain and imaging studies revealed a dilated intestine with possible perforation. The patient was brought into surgery and a volvulus was discovered to be the cause of the 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. The patient could not be weaned off of the ventilator postoperatively and the family decided to withdraw life support.

Question(s) For Expert Witness

1. What are the signs and symptoms that should have pointed to this diagnosis in a timelier manner and would earlier intervention have altered the outcome?

Expert Witness Response E-001381

The signs and symptoms depend on the degree of ischemia. Manifestations can range from lymphatic and venous congestion with simple edema to full intestinal necrosis secondary to arterial and venous thrombosis. Once intestinal ischemia develops, pain becomes a more pronounced symptom, and the patient may have signs of an acute abdomen with rigidity and tenderness to palpation. Because the vascular territory of the SMA includes the distal duodenum to the midtransverse colon, the entire midgut may become necrotic and nonviable if the volvulus is not corrected in time. Necrosis of the entire midgut is incompatible with life.