Complications of Ulcerative Colitis

Case Summary

Allegations: Failure to timely diagnose and treat toxic megacolon.

This case involves a 27 year old, female newlywed graphics designer without a significant PMH. On October 27, the patient went to her PCP complaining of mucinous / bloody diarrhea x 3 days. She had just been vacationing in upstate NY and her physician, suspecting infectious colitis, performed stool cultures and prescribed Flagyl. At that time the patient weighed 151 lbs. Three days later, the patient called her doctor to report a worsening of symptoms. The physician advised the patient that the stool cultures had returned negative and that he wanted her to be seen by a gastroenterologist. The physician instructed his staff make an appointment for the patient.

The appointment with gastroenterologist occurred on November 1st. The gastroenterologist documented that the patient was experiencing 10 - 15 bloody BM’s per day for 2 weeks. The only physical exam finding documented was a weight of 141 lbs. The plan was for the patient to have a colonoscopy. The lower endoscopy was performed a few days later, revealing ulcerations extending from the rectum to the cecum. The gastroenterologist diagnosed ulcerative colitis and prescribed prednisone and asacol. No clear follow-up plan was delineated for the patient, and she was discharged that evening from the facility where the colonoscopy had been performed.

Ten days later, the patient’s husband contacted the gastroenterologist secondary to a concern about his wife’s weakness and apparent dehydration. The gastroenterologist told him to bring the patient to the emergency department. The gastroenterologist saw the patient in the ED and started IV fluids for dehydration and solumedrol for the ulcerative colitis. The patient was then discharged from the ED with a plan to follow-up with the gastroenterologist in 1 week. At deposition, the husband stated that he contacted the gastroenterologist several times during this period to report that his wife was failing to improve. There was no documentation of these calls in the patient’s medical record.

When the physician was asked about these phone conversations he stated that he believes he may have spoken with the husband on a few occasions but he could not recall the content of the conversations. He explained that he usually tries to document telephone conversations with family members but that he must have been very busy at the time of these calls, and therefore, he may not have done so in this case.

The patient, accompanied by her husband, followed up with the gastroenterologist as planned on November 18. At this point, the patient weighed 125 lbs, had no appetite, and was reporting 5 non-bloody BM’s per day. The gastroenterologist told the patient that she needed to go to the hospital for IV hydration and IV corticosteroids. The patient initially refused but was persuaded by the gastroenterologist and the husband to follow through with the plan, and the patient was sent to the hospital as a direct admission. On hospital day #2, the diarrhea had not subsided. The gastroenterologist prescribed Lomotil and ordered a dietary consult with a nutritionist.

On hospital day #4, the gastroenterologist documented that if things did not improve, he would consider transferring the patient to another hospital under the care of an inflammatory disease specialist with whom he had been in contact. On the following day, the patient’s condition had not improved substantially, and at deposition, the gastroenterologist stated that a discussion ensued between him and the patient about the possibility of transferring her care to another facility with an IBD specialist. This conversation and the patient’s refusal were not documented in the patient’s medical record.

On hospital day #7, the gastroenterologist documented that the patient had two well-formed, non-bloody BM’s over the past 24 hours, and was discharged in stable condition with a prescription for 6-mercaptopurine, prednisone, and Lomotil. At deposition, the plaintiff’s attorney contrasted the gastroenterologist’s note with contemporaneous notes written by a nurse and a PA, both of whom described loose stools, complaints of abdominal pain, and "hypoactive" to "absent" bowel sounds. The gastroenterologist responded to the discrepancy by saying that he was never made aware of the PA or RN’s findings.

No imaging studies were performed over the course of this hospital stay. At the time of discharge, the gastroenterologist told the patient that they should give the medication more time to work and that he would like the patient to see an inflammatory disease specialist. The gastroenterologist contacted the specialist and had an appointment made for the patient to see the specialist in three weeks.

Two days after returning home, the patient’s husband contacted the gastroenterologist by telephone to report that his wife was very weak. The gastroenterologist said that his wife had become anemic over the course of the hospitalization and instructed him to bring the patient to an ambulatory surgical center where she would receive a blood transfusion. The patient developed a fever at the facility and the staff reassured the husband that this was a reaction to the blood transfusion. As a result, the gastroenterologist was never informed of this change in the patient’s status. The gastroenterologist did not see the patient at the ambulatory center and the patient was discharged home 6 hours after the transfusion.

Three days later, on December 2nd, the patient went to the gastroenterologist’s office to inform him of worsening abdominal pain. The gastroenterologist said that he was leaving the following day for a three week vacation, and had a copy of the patient’s chart made. He gave the husband the chart copy and said that if his wife’s condition worsened, they should take the chart copy to a hospital where he knew a gastroenterologist to be available. No direct communications were made to this gastroenterologist. The gastroenterologist did send a letter to the PCP alerting him that he would be on vacation and advised him of his treatment and recommendation for the patient.

On December 3rd, in a worsening state, the patient presented to the hospital as directed by the gastroenterologist. She now had a temperature of 101.1 and a 48% bandemia. A CT of the abdomen revealed colonic dilation and the patient was admitted under the gastroenterology service with refractory ulcerative colitis rule out sepsis, rule out megacolon. The patient was started on IV antibiotics and continuous IV steroids. On the morning of December 6th, the gastroenterologist noted that the patient was still doing poorly, and he informed her that he would like a surgeon to consult on the case. The patient and her husband said that they did not want her to have surgery at that hospital, and they asked that her care be transferred to a tertiary care facility which had more experience with inflammatory bowel disease.

The gastroenterologist stated at deposition that he believed the transfer needed to occur "ASAP" and he called the specified facility and spoke directly to the colorectal surgeon and IBD specialist, both of whom approved the transfer. The gastroenterologist stated that he was not that familiar with the inter-institutional transfer process but believed it was orchestrated by the receiving facility. He additionally stated that the receiving physician had assured him that he would "take care of it". The following day, while on rounds, the gastroenterologist discovered that the patient had not been transferred. He asked the nurse why the patient was still at the hospital. The nurse stated at deposition that this was the first time she was aware that the patient was to be transferred.

The nurse contacted the receiving facility on December 7th at 10AM but was told that Admitting would not approve the transfer until they had an authorization from the patient’s insurance company. By noon, the insurance company approved the transfer and the RN called the gastroenterologist to sign the transfer paperwork. At 1:30PM, the transfer paperwork was signed, and by 2:00PM the receiving institution approved the transfer. At 3:00PM the nurse contacted the gastroenterologist to inform him that she needed his approval to obtain an ACLS ambulance transport because the patient was receiving potassium repletion IV and the facility’s standard ambulance transportation could not operate IV treatments en route.

At 9:00 PM on December 7th, 36 hours after the initial request for a transfer, the patient arrived at the receiving institution. The following morning, a total colectomy was performed. Multiple perforations of the colon were noted. The patient died 2 days later. In a damaging affidavit, the surgeon claimed that had he performed the surgery two days prior, he could have saved this patient’s life.

Comments

The experts who reviewed this case offered the following medical deviations in the case:

  • Overall, significant deficiencies were observed in the gastroenterologists charting. On the initial visit, the only physical exam finding documented was the patient’s body weight, despite the patient’s fairly significant complaints. The fact that an examination of the patient’s abdomen was not performed on this visit and the failure to perform a rectal exam throughout this patient’s course were seen as departures by the experts.
  • It was opined that acute severe ulcerative colitis is a medical emergency that requires intensive medical monitoring and it was felt by the experts reviewing the case that the physician here failed to appreciate the emergent nature of this patient’s illness.
  • The experts felt that a patient with severe ulcerative colitis in the hospital requires nearly daily abdominal x-rays to evaluate for megacolon. The fact that during this patient’s 7 day hospitalization an abdominal film was never performed was viewed as a departure by the experts.
  • It was opined that 30% of severe UC cases are steroid-refractory, and that because of this, it is appropriate to seek colorectal surgical consultation early on in the course of inpatient medical management. This step helps to avoid delays in decision making about treatment escalation. The failure to incorporate surgical expertise into this patient’s plan was, therefore, viewed as a departure.
  • The patient was discharged from the hospital based on a decrease in BM frequency; however, this patient was placed on Lomotil which confounded the patients BM pattern, making this a less than reliable criteria for actual improvement. Additionally, the failure to radiographically rule out colonic dilatation meant that one could not be reasonably certain that the decrease in bowel movements was not due to a developing megacolon. For these reasons, it was felt the patient’s discharge from the hospital was premature.
  • Following the hospital discharge, the patient’s husband called to report that his wife was very weak. It was felt by the experts that this warranted further evaluation by the gastroenterologist including hospitalization. Without actually seeing the patient, it was seen as a departure to attribute the patient’s weakness to anemia.
  • Prescribing Lomotil which has been reported to induce toxic megacolon in patient’s with acute ulcerative colitis.
  • At deposition, the gastroenterologist said that he had never before seen a case of toxic megacolon. In light of his limited exposure to the complications of ulcerative colitis, the experts opined that the gastroenterologist should have been more proactive in consulting with a more experienced specialist.

Risk Management Points

  • In the original referral, the PCP directly contacted the gastroenterologist, communicated his concerns over the patient’s condition, and had an appointment made on behalf of his patient. This was thought by the experts to be good practice. Of note, the PCP was not named in this suit.
  • Lack of documentation of conversations with the patient and her husband was recognized to be a weakness in the defensibility of this case. An emerging pattern of a deteriorating clinical course may have been more evident to the gastroenterologist had he documented his communication with the patient and husband at each contact. The physician acknowledged that this was a deficiency in his practice and as a result of this case he now documents all telephone calls.
  • The failure to consult with a gastroenterologist with more experience in managing severe ulcerative colitis was noted by the experts reviewing this case. Since this case, the gastroenterologist has strengthened his relationships with GI sub-specialists and readily asks for additional opinions when faced with uncertain and complex clinical presentations.
  • The failure to document the refusal made by this patient to have his care transferred to an inflammatory disease specialist was seen as a weakness in this case. As a result of this suit, the physician stated that he now documents the conversations he has with patients surrounding all refusals of care. A note documenting the patient’s refusal of care perhaps could have assisted the physician in the defense of this case. Because no note was present, a plaintiff attorney could point out to the jury that a retrospective assertion of patient refusal is self-serving to the physician’s defense.
  • Failure to arrange for any coverage for the patient prior to the gastroenterologist’s departure on vacation. The experts reviewing the case believed that the gastroenterologist should have:
    1. been in direct contact with a covering gastroenterologist.
    2. better prepared the patient and her husband by providing the name and contact information to the covering gastroenterologist.
    Physicians must assure adequate coverage to patients in their absence and this responsibility certainly increases in the face of a rapidly deteriorating clinical course. The letter sent by the gastroenterologist to the PCP was thought to be inadequate because the PCP did not have the expertise to manage this patient. The handoff of this patient needed to be made to a physician with equivalent or greater qualifications. As a result of this case, the physician has established a relationship with other gastroenterologists in the community with whom he can arrange coverage.

Case Disposition

The case was settled on behalf of the gastroenterologist.