23 year old US Navy lieutenant admitted on 7/19/21 to Pensacola community hospital for epigastric abdominal pain, abdominal cramping and diarrhea with some bloody stools for 2-3 weeks.. GI specialist performed EGD followed by colonoscopy, which he felt showed severe pan diffuse colitis throughout colon. Patient tested Tested positive for campylobacter and prescribed antibiotics. GI believed most likely ulcerative colitis. and signed off. GI service reconsulted 5 days later for persistent bloody diarrhea. Prescribed steroids, which were increased after 4 days. Patient discharged home on 8/1 with a plan to be followed by GI as outpatient with Entyvio therapy if no improvement.
Patient returned on 8/4, 3 days later with continued abdominal pain and bloody diarrhea. IV steroids were recommenced. GI performed colonoscopy on 8/6. Found pancolitis in colon with small ulcerations, complete loss of normal vascular pattern. GI initiated infliximab on 8/8, the day the patient was discharged with instructions to follow up with GI on outpatient basis in 2 days. He was tolerating oral diet at time of discharge.
Patient returned to hospital on 8/16. He reported inability to keep hydrated, large amounts of diarrhea and bloody stool, and passing out when he stands. During this admission, it was noted that the patient had lost 50 pounds since the initial diagnosis. TPN was not offered. There were unsuccessful attempts to advance diet. Surgery was following patient and colectomy was being considered. A second dose of infliximab was administered on 8/23/21.
The patient was transferred on 9/1/21 to a hospital in South Carolina for a higher level of care. The next morning, the patient showed peritoneal signs. Emergent total abdominal colectomy with extensive washing of the abdominal cavity, end ileostomy, was performed for an acute on chronic perforation of the cecum with fecal peritonitis. TPN was administered for the first time on 9/3.
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Do you believe there might have been medical error?
The case describes a 23 y/o patient with hematochezia and endoscopy revealing pan colitis. It appears the physician was appropriately working up infectious colitis and inflammatory bowel disease. The patient was treated for campylobacter. It is not stated whether clostridium difficile colitis was ruled out (this should have been documented by the physician). It is also not stated if biopsies were obtained on either colonoscopy. It is also unclear why the second colonoscopy was performed. In the absence of infectious colitis it appears the patient likely has severe inflammatory bowel disease. The patient was not aggressively treated for severe inflammatory bowel disease. IV steroids and antibiotics should have been started earlier when evidence the patient was not improving (GI re-consult and the patient had to return to the hospital multiple times). The patient appear to have been getting worse with each readmission. This suggests a diagnosis was missed or under treated.
Do you believe there might have been causation (i.e. the medical error resulted in an injury)?
Yes. It appears the diagnosis was missed or under treated. Specifically an infectious cause of colitis may have been missed (the case details did not include). If the patient had suspected severe inflammatory colitis as supported by pan colitis on two colonoscopies (mayo ibd score for severity was not provided), and a series of gi re-consults on the same admission and multiple readmissions. If severe colitis had been recognized empiric treatment for both infectious and inflammatory bowel disease could have been started earlier (the index admission).
What makes you a good expert for this case?
I am a GI provider in the texas medical center tertiary care hospitals for 10 years. I have treated numerous infectious and severe inflammatory bowel disease patients in the inpatient and outpatient setting.
How often do you encounter cases similar to this one in your practice?
I see patients with inflammatory bowel disease weekly and encounter similar cases of severe colitis on a monthly basis.
Do you believe there might have been medical error?
Much is missing from this abbreviated history. Why did the GI sign off after calling it Ulcerative Colitis without follow up or specific therapy for 4 days? What dose of Remicade was given? What was his albumin level? Why wasn’t the patient followed in the hospital to ensure response after the first Remicade dose. Can’t really assess with this limited case history.
Do you believe there might have been causation (i.e. the medical error resulted in an injury)?
This patient seems to have had fulminant colitis with unclear but seemingly minimal follow up while in the hospital.
What makes you a good expert for this case?
I am an IBD specialist at Mount Sinai in NYC, one of the premier centers in the country. This has been my focus for over 20 years. We are experts at the management of fulminant UC.
How often do you encounter cases similar to this one in your practice?
Routinely. Patients such as this are transferred to your hospital regularly.
Do you believe there might have been medical error?
There are a few elements of particular interest which may point to a medical error/negligence: -"Prescribed steroids, which were increased after 4 days." If steroids had to be increased after 4 days (unusual in the inpatient setting), why was the patient discharged (e.g. as opposed to monitoring for a longer period of time, starting a biological therapy in-hospital)? -"GI initiated infliximab on 8/8, the day the patient was discharged with instructions to follow up with GI on outpatient basis in 2 days. He was tolerating oral diet at time of discharge." It's rare (if ever), in my experience, to discharge a patient with severe colitis on the day of their first infliximab infusion; we generally will monitor patients for another 24-48 hours, sometimes more. This is a generally accepted standard of care. Also, was the patient discharged on steroids as well, and if so, what dose? Lastly, what exactly is meant by "tolerating oral diet"? Does this mean that he was able to have clear liquids without vomiting them up? That would be insufficient in a case like this-- the patient would need to be able to eat, without worsening abdominal pain or bloody bowel movements, and eat enough calories to be nutritionally replete (which, as we can see, became a problem in this patient's case). -What happened during the 8/8 and 8/16 period of time? Was the patient seen as an outpatient? What medications was he on and at what dose? Was there a downtrend in inflammatory markers to indicate that it was safe to discharge the patient on 8/8?
Do you believe there might have been causation (i.e. the medical error resulted in an injury)?
Without having some of the information alluded to in the response to the prior question, it's difficult to determine to what degree there is causation, but overall it seems to me that the outcome (cecal perforation, surgery) could have been avoided had there not been a deviation from the standard of care.
What makes you a good expert for this case?
I have clinical and published research experience in the management of inflammatory bowel disease, including severe disease and complications of disease. I'm also a patient advocate and can often spot where there have been deficiencies in care and associated causation, even when otherwise not apparent to the less experienced reviewer.
How often do you encounter cases similar to this one in your practice?
I have seen cases where proper/adequate medical therapy of IBD has resulted in serious complications such as toxic megacolon, perforation, emergency surgery, fistulization, etc.
Do you believe there might have been medical error?
The standard of care for management of patients with acute severe ulcerative colitis requires close monitoring of response in the inpatient setting. Typically this involves starting intravenous, steroids and monitoring for symptom and laboratory response. If there is no response or an adequate response after three days of IV steroids, the patient should remain in the hospital to initiate biologic therapy or surgery. If there is an adequate response to biologic therapy, the options are to give an early dose of the biologic or proceed to surgery. Acute, severe ulcerative colitis carries a risk of toxic megacolon and perforation, so does require close monitoring in the inpatient setting. From the case description it seems like this patient was discharged too soon on more than one occasion.
Do you believe there might have been causation (i.e. the medical error resulted in an injury)?
This patient more likely than not was going to need surgery given the inadequate response to both IV steroids and Remicade. That being said, this likely could’ve been recognized sooner and done on a more elective basis without him, suffering, a bowel perforation, and the risk inherent with a bowel perforation
What makes you a good expert for this case?
I have additional training in inflammatory bowel disease and regularly treat IBD in my practice using conventional therapies, biologic therapies, small molecules, and then refractory cases surgical resection
How often do you encounter cases similar to this one in your practice?
I frequently see ulcerative colitis, which is refractory to medical therapy and requires surgery. These patients are often seen in the hospital or sent to the hospital for acute severe ulcerative colitis flares.
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