When a patient has gastrointestinal (GI) problems, physicians and surgeons often use diagnostic radiology studies to help them identify the problem. Unfortunately, some doctors rely so much on radiology images that they forget about the patient right in front of them.
Common GI complaints include abdominal pain, difficulty swallowing, nausea and vomiting, and just an overall difficulty in keeping food or liquids down. These types of symptoms can develop on their own, or after an abdominal surgery like a hiatal hernia repair or bariatric procedure.
For post-surgical patients, the standard of care requires surgeons to investigate every potential cause of the patient’s GI problems. This is called the differential diagnosis process. When surgeons or physicians take a shortcut and skip the differential diagnosis steps, it can place the patient in grave danger.
Hiatal hernia surgery
For example, I’m currently working on a case where a woman died after a straight-forward hiatal hernia surgery.
A hiatal hernia is a condition where a part of the stomach pokes through the hiatus, a hole in the muscular diaphragm where the esophagus connects to the stomach. The surgery involves pulling the stomach down to the proper position below the diaphragm, usually making a stitch or two to tighten the hiatus to prevent another herniation.
After her surgery, the patient immediately started having problems. She wasn’t waking up and becoming responsive and her blood pressure plummeted. They transferred her to the intensive care unit (ICU) and lab work already showed signs of infection.
A surgeon was called, who wrote in the medical record that she suspected sepsis. Sepsis is a potentially life-threatening inflammatory condition that can follow a bad infection. The surgeon ordered an esophagram (barium swallow) to investigate the issues.
What is a barium swallow (esophagram)?
An esophagram is study where a patient swallows a barium contrast drink that shows up on an x-ray as the liquid travels down the throat and esophagus, through the hiatus and into the stomach.
As the name of the study suggests, it’s designed to identify problems with the esophagus, like strictures, ruptures, or perforations.
What’s strange about the surgeon’s selection of a barium swallow study is that no problem with the esophagus that might be discovered would explain the patient’s signs of infection and sepsis. An accidental perforation of the stomach or bowel, though, should be at the top of the surgeon’s differential diagnosis list.
Surgical experts generally agree that causing a hole, tear, or perforation in the bowel or stomach by accident during surgery doesn’t violate the standard of care. The problem comes, though, when a patient has signs of infection and the surgeon doesn’t fully rule them out.
Abdominal CT is the gold standard
The surgical expert that we hired to review the medical records in this case has testified that there are only two ways to rule out a perforated stomach or bowel. One is to order an abdominal CT scan. The other is to return the patient to the operating room for an exploratory surgery.
Unfortunately, the surgeons did neither and, as a result, the patient’s gastric perforation went undiagnosed, leaking toxic contents into the abdomen and causing a massive infection, septic shock, and death.
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Robert Painter is a medical malpractice attorney at Painter Law Firm PLLC, in Houston, Texas. He is a former hospital administrator who represents patients and family members in medical negligence and wrongful death lawsuits against hospitals, physicians, surgeons, anesthesiologists, and other healthcare providers. A member of the board of directors of the Houston Bar Association, he was honored, in 2018, by H Texas as one of Houston’s top lawyers. In May 2018, the Better Business Bureau recognized Painter Law Firm PLLC with its Award of Distinction.