A 42-year-old male with a history of diverticulitis was referred to the emergency department by his family physician after complaining of coughing, shortness of breath, and an oxygen desaturation of 60%. Upon admission to the hospital, the patient was diagnosed with pneumonia, intubated, sedated, and given antibiotics. In the following week, a pulmonologist referred the patient for exploratory surgery for possible ileus perforation. The general surgeon reviewed the CT imaging and found no signs of free air or perforation. On the same day, the general surgeon determined that due to the growth of gram-negative rods of E. coli identified during a recent thoracentesis, perforation may be possible. One week later, a CT scan of the abdomen and pelvis with IV contrast revealed a collection of free air and fluid in the small intestine, but it was unclear whether this was a sign of perforation. As a result of the patient’s unstable respiratory status and sepsis, drains were placed by the general surgeon. A surgeon’s partner then took over the patient’s care. Due to the patient’s unchanged clinical condition, the first general surgeon returned to care and performed an ex-laparotomy that revealed a perforated bowel. An urgent operative repair was performed, and the patient was transferred two days later to another hospital. The patient died the next day. ARDS, septic shock, and perforated diverticulitis are listed as the immediate causes of death on the patient’s death certificate.
Perforation of the gastrointestinal tract may be suspected based upon the patient’s clinical presentation. The diagnosis becomes obvious through a report of extraluminal “free” gas or fluid collection on diagnostic imaging. Surgical consultation should be pursued early in any patient with abdominal pain and signs of clinical deterioration. An exploratory laparoscopy is often performed to obtain information that is not available via clinical diagnostic methods. Once the underlying pathology has been determined, laparoscopy may continue as a therapeutic surgical procedure. The increasing availability of laparoscopy as a minimally invasive means of inspecting the abdomen has further reduced exploratory laparotomy applications. A hemodynamically unstable patient cannot compensate for the physiological changes imposed by the capnoperitoneum. Laparotomy contraindications include sepsis, hemodynamic instability, or metastatic malignant diseases. Treatment of a patient with suspected bowel perforation involves establishing intravenous (IV) access and initial hemodynamic management, especially if the patient presents with any signs or symptoms of sepsis or shock. Initiation of broad-spectrum antibiotics aimed at gram-negative and anaerobic organisms is essential and should be initiated early. If the patient is hemodynamically stable and there is no concern for peritonitis, such as in the case of spontaneously contained perforation, the option for non-surgical management with antibiotics and observation may be considered. However, most cases will require direct investigation via laparoscopic or open laparotomy exploration. In this case, a delay in identification of the perforation and repair were significant factors in the death of this patient.
Expert Witness Specialty/Specialties
Expert Specialty: General Surgery with bariatric expertise.
Questions for the Expert Witness
- Under what circumstances should operative management for suspected bowel perforations be withheld?
- Was placing of drains an appropriate measure for this patient?
- How did a delay in diagnosis and surgical repair affect the patient’s prognosis in this case?
Expert Witness Involvement
A general surgeon in this case can speak to the standard of care for a similar patient. In addition, they can identify the protocol for performing an exploratory laparotomy in a suspected bowel perforation.