The matter concerns a 52 year old woman who went to her PCP, on 12/12/2025, following ten (10) days of no BM, cramps at lower abdominal and pelvic pain. Of note, she is on tramadol for other reasons, and even that was not helping her abdomen pain.
PCP performed a physical examination, noting, abdomen mildly distended with hyperactive bowel sounds, diffuse lower abdominal pelvic area tenderness with rebound tenderness in the midline and in the LLQ. Based on that, PCP recommended she goes directly to the ER, he believed it was a surgical EMG (per medical report, verbal to pt. too). She goes to ER. A physical examination is performed noting unremarkable abdominal exam. CT done with contrast of her ABD/PELVIS. Imaging shows acute sigmoid diverticulitis, large stool burden through the colon; and 2 cm calcified splenic artery aneurysm. Also from a pathology POV, her WVC, platelet, auto neutrophil and monocyte, respectively where flagged “H” – given the diverticulitis diagnosis that is maybe a given. She was not seen by gastro., and I do not see a consult with gen. surgery. She was D/C home with antibiotics for the diverticulitis, nothing for the stool burden, and told to return should symptoms persist. Pt. is obese.
12/14/2025, she returns to ER symptoms are worse. Repeat CT is done showing now, redemonstrated acute sigmoid diverticulitis, with new small foci of intraperitoneal free air and small lower abdominal ascites, concerning for perforation. Reactive inflammatory changes of the terminal ileum and cecum. Locules of air in the region of the caudate lobe. Diagnosed with perforated sigmoid diverticulitis, intra-abdominal abscess, possible secondary bacterial peritonitis, leukocytosis.
12/15 repeat CT was done no change and she goes into surgery.
OR notes: exploratory laparotomy, sigmoid colon resection, creation of colostomy in the left lower quadrant, extensive drainage of fecal peritonitis; drainage of pelvic abscess; drainage of the suprahepatic abscess, repair of multiple serosal tears of the small bowel. Four hour plus surgery. Kept for observation for two (2) weeks.
To date, she still has colostomy bag, probably until March/April she was told, per DR.
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Do you believe there might have been medical error?
Initial management for uncomplicated diverticulitis includes antibiotics, or in some cases no antibiotics, but no specific recommendation for management of stool burden. Unless evidence of perforation or significant abscess was missed on the initial CT scan, I do not see obvious deviation from standard care as not all patients respond to antibiotics, and the inflammatory process can evolve into a perforation scenario, for which she received the appropriate surgery.
Do you believe there might have been causation (i.e. the medical error resulted in an injury)?
Initial management for uncomplicated diverticulitis includes antibiotics, or in some cases no antibiotics, but no specific recommendation for management of stool burden. Unless evidence of perforation or significant abscess was missed on the initial CT scan, I do not see obvious deviation from standard care as not all patients respond to antibiotics, and the inflammatory process can evolve into a perforation scenario, for which she received the appropriate surgery.
What makes you a good expert for this case?
20 years in general Gastroenterology, practice, board certification, full time academic teaching hospital environment
How often do you encounter cases similar to this one in your practice?
Diverticulitis or the concern for diverticulitis is a very common complaint. I probably see a few patients every month with such concerns.
Do you believe there might have been medical error?
Acute uncomplicated diverticulitis meaning no perforation or abscess can be trialed with oral antibiotics. It does not require GI or surgical consultation
Do you believe there might have been causation (i.e. the medical error resulted in an injury)?
As above, the initial presentation was negative and was appropriately managed with antibiotics and instructions to return
What makes you a good expert for this case?
I regularly see patients with diverticulitis
How often do you encounter cases similar to this one in your practice?
I see patients with diverticulitis a few times a month
Do you believe there might have been medical error?
It is unclear why her emergency note documented an unremarkable abdominal examination given her PCP‘s finding of a tender abdomen with rebound. Was more than one abdominal examination performed during her time in the emergency room? If they noted that an acute abdomen was present they might have called a surgical consult to see the patient sooner. Additionally, after the CT scan on 12/14/25 why we was she not taken to the operating room right away and why was there a repeat CT scan performed the next day on 12/15/25? This seems to have caused a delay in her operative treatment.
Do you believe there might have been causation (i.e. the medical error resulted in an injury)?
Appreciating the severity of her diverticulitis sooner might not have prevented the perforation, but might have led to earlier surgical intervention and perhaps a shorter hospitalization.
What makes you a good expert for this case?
I am a gastroenterologist that treats patients with diverticulitis.
How often do you encounter cases similar to this one in your practice?
I see 1-2 patients a year with uncomplicated diverticulitis. I see complicated diverticulitis, with an abscess or perforation less commonly, perhaps one case every 4-5 years.
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