Volvulus Misdiagnosis Lawsuits

Volvulus is a twisting of the intestine around itself and can occur in childhood. You will also hear volvulus described simply as a twisted bowel or twisting of the intestines. Volvulus results in a blockage that can restrict blood flow and result in tissue damage.

There are several different types of volvulus. Midgut volvulus involves the small intestine and is often associated with intestinal malrotation in infants and children. Gastric volvulus involves twisting of the stomach. Colonic volvulus is usually classified as sigmoid volvulus or cecal volvulus.

The incidence and prevalence of gastric volvulus is not known due to the fact that many cases of chronic volvulus go undiagnosed. Acute gastric volvulus is a very dangerous condition with reported mortality rates of approximately 30% to 50% when treatment is delayed.

Approximately 10% to 20% of gastric volvulus cases occur in infants less than 1 year of age, although gastric volvulus is more common in older adults.

Gastric volvulus can be classified as primary or secondary. Primary gastric volvulus results from laxity or abnormalities of the gastric ligaments. Primary gastric volvulus is more common in adults but has also been reported in children. Secondary gastric volvulus is usually associated with acquired or congenital abnormalities resulting in abnormal mobility of the stomach.

Congenital abnormalities associated with volvulus include diaphragmatic defects, gastric ligament abnormalities, abnormal attachments or adhesions, asplenism, small- and large-bowel malformations, pyloric stenosis, colonic distension, and rectal atresia.

Certainly, there are volvulus cases that could not have been avoided. But, regrettably, many of these cases could have been avoided if the doctor had simply done what a good doctor would have done. If you or someone you love has been hurt and you suspect negligence was the cause of the injuries or death, call 800-553-8082 or get a free online consultation.

Symptoms of Volvulus

Children with volvulus may experience bloody or deep red stools, constipation, abdominal distension, abdominal pain or tenderness, vomiting green material, nausea and/or shock. Symptoms can develop quickly and most are severe, requiring immediate medical attention in the emergency room.

In newborns and infants, green or bilious vomiting is particularly important. Bilious vomiting can be a warning sign of a volvulus bowel obstruction, particularly malrotation with midgut volvulus. It should not automatically be written off as reflux, formula intolerance, or an ordinary stomach illness.

Sigmoid volvulus symptoms more commonly include abdominal distension, abdominal pain, constipation, and inability to pass stool or gas.

A twisted bowel can become dangerous very quickly if the twisting restricts the blood supply to the intestine. There is no reliable answer to how long someone can live with a twisted bowel because the danger depends on whether blood flow has been compromised and how much bowel is involved.

Diagnosis of Volvulus

Diagnosis depends on the type of volvulus involved.

In children with suspected malrotation and midgut volvulus, diagnosis often requires examination of the upper gastrointestinal tract with an upper GI contrast study. Ultrasound is also increasingly used and can be very effective in experienced hands.

Abdominal X-rays may show evidence of intestinal obstruction. However, in midgut volvulus, abdominal X-rays may appear normal. A normal X-ray does not rule out volvulus.

Ultrasound may show the “whirlpool sign,” created when the bowel and mesenteric vessels twist around the superior mesenteric artery.

Blood tests and evaluation of electrolytes may also be useful. Blood work can show dehydration, infection, metabolic acidosis, or other evidence that the bowel is becoming ischemic, but laboratory tests cannot by themselves rule volvulus in or out.

In cecal volvulus, CT scanning is now particularly important because it can identify the site of the obstruction, twisting of the bowel and mesentery, and possible signs of ischemia or perforation.

The important point is that diagnosis requires the physician to consider volvulus in the first place. The right test depends on the age of the patient, the symptoms, and which part of the gastrointestinal tract is suspected of twisting.

Risk Factors for Volvulus

Children with a birth defect known as intestinal malrotation are at risk of developing volvulus. Volvulus usually occurs within the first year in children with intestinal malrotation, although it can occur later in childhood and even in adults.

Other small bowel volvulus causes include congenital abnormalities, adhesions from prior surgery, and other conditions that allow the intestine to move or rotate abnormally.

Volvulus does not seem to be associated with race or ethnicity.

Sigmoid volvulus is more commonly associated with prolonged constipation, chronic mental or neurological illness, institutionalization, prolonged bed rest, and old age, whereas cecal volvulus tends to occur in somewhat younger patients.

The causes of sigmoid volvulus usually involve both anatomy and risk factors. A long, redundant sigmoid colon attached to a relatively narrow mesenteric base makes it easier for the colon to twist.

Sigmoid volvulus is also more common in people with a high-fiber diet, chronic constipation, and frequent laxative use. You see sigmoid volvulus in patients in nursing homes or those who are otherwise bedridden. Prior abdominal surgery can also put you at greater risk of volvulus.

Not surprisingly, a big risk factor for volvulus that some doctors inexplicably miss is a prior history of volvulus, particularly patients who were previously treated for sigmoid volvulus with endoscopic or sigmoidoscopic reduction.

Sigmoid and Cecal Volvulus

Sigmoid volvulus and cecal volvulus both involve a twisted colon, but their management can be very different.

Sigmoid volvulus occurs when the sigmoid colon twists around its mesentery and causes a large bowel obstruction. Abdominal X-rays may show the classic markedly dilated loop of sigmoid colon sometimes described as a “coffee bean” appearance. CT scanning may be needed when the diagnosis is uncertain or when there is concern about ischemic bowel.

When there is no evidence of bowel necrosis, perforation, or peritonitis, colonoscopic or flexible endoscopic decompression is often successful for sigmoid volvulus.

But sigmoid volvulus has a high recurrence rate after decompression alone. A patient who responds to endoscopic reduction still needs a plan to address the risk that the colon will twist again.

Cecal volvulus is different. Endoscopic decompression has a much lower success rate and is generally not considered definitive treatment. Patients with cecal volvulus usually require prompt surgical evaluation.

This distinction is important because misdiagnosis of the type of volvulus can cause a dangerous delay in treatment.

Gastric Volvulus

Gastric volvulus involves twisting of the stomach rather than the intestine.

Primary gastric volvulus can result from laxity of the gastric ligaments. Secondary gastric volvulus may be associated with diaphragmatic defects, paraesophageal hernias, adhesions, and other congenital or acquired abnormalities.

Acute gastric volvulus can obstruct the stomach and restrict its blood supply. If the stomach becomes strangulated, the patient can develop ischemia, necrosis, perforation, sepsis, and death.

Treatment depends on the cause and severity. A patient with acute obstruction or compromised blood flow generally requires urgent intervention and often surgery.

Gastric volvulus surgery recovery time varies tremendously depending on what doctors find. A patient who undergoes an uncomplicated repair has a very different recovery from someone who already has necrotic stomach, perforation, sepsis, or other organ damage.

Treatment and Outcomes

Treatment depends on the type of volvulus.

In children with midgut volvulus, surgery is usually required to repair the volvulus by cutting into the abdomen and untwisting the bowel to restore blood supply. The surgeon also addresses the underlying malrotation and determines whether the bowel is still viable.

In cases where blood flow has been restricted and resulted in necrotic bowel tissue, the affected segment of bowel may be removed and the ends sewn together or used to connect the intestines to the outside to allow bowel contents to be removed through an ileostomy or colostomy.

Cecal volvulus usually requires surgery.

Sigmoid volvulus can often be treated initially with endoscopic decompression if there is no evidence of ischemia, perforation, or peritonitis. Because the recurrence rate is high, definitive surgery is often recommended after successful decompression.

Quick diagnosis and treatment of volvulus usually has a positive outcome. If the bowel is necrotic, the prognosis is poor and may be life-threatening depending on the amount of bowel that is dead.

Complications may include secondary peritonitis, inflammation of the abdominal lining, sepsis, perforation and, after removal of a large portion of the small bowel, short bowel syndrome.

Bowel Necrosis and Short Bowel Syndrome

The most serious danger with a missed volvulus is that the twisting does more than create an obstruction. It can also cut off the blood supply to the bowel.

If the bowel remains twisted long enough, the tissue becomes ischemic and can eventually die. Once bowel tissue is necrotic, it usually has to be surgically removed.

After removal of a large portion of the small intestine, a patient may develop short bowel syndrome. This can interfere with the body’s ability to absorb nutrients and fluids and may require long-term nutritional support, repeated hospitalizations, medications, or additional surgery.

In a malpractice case, this is often why the timing of diagnosis becomes so important. Bowel that could have been saved when the patient first came to the hospital may be dead by the time the correct diagnosis is finally made.

Misdiagnosis

Clinicians may not consider a clinical diagnosis of malrotation after childhood because of its low incidence. However, patients with malrotation can present with obstruction and ischemia or chronic abdominal pain associated with volvulus. Diagnosis usually requires a high degree of suspicion and as a result can go undiagnosed.

Due to the non-specific symptoms in children such as vomiting, abdominal pain and nausea, as well as difficulties in pediatric examination, surgical emergencies such as malrotation with volvulus are often delayed or missed and can be among the more difficult diagnoses for emergency physicians.

One of the most important warning signs in an infant is bilious vomiting. A baby with green vomiting may have an intestinal obstruction until proven otherwise. Sending the child home with a diagnosis of reflux or gastroenteritis without adequately considering volvulus can be a catastrophic mistake.

Diagnosis is difficult, and another potentially dangerous error is the misdiagnosis of the type of volvulus, particularly sigmoid versus cecal.

A normal abdominal X-ray does not eliminate midgut volvulus. Likewise, a patient responding to colonoscopic decompression does not mean the underlying problem can simply be forgotten. Sigmoid volvulus can recur, while cecal volvulus generally requires surgical management.

The important question is whether the physician recognized the warning signs and ordered the appropriate imaging and surgical consultation before the bowel lost its blood supply.

When Is a Missed Volvulus Medical Malpractice?

Certainly, there are volvulus cases that could not have been avoided. Some patients arrive at the hospital after bowel damage has already occurred.

But there are also cases where the warning signs were there and the diagnosis should have been made sooner.

A volvulus malpractice case may involve failing to recognize bilious vomiting in an infant, dismissing continued abdominal pain and distension, relying on a normal abdominal X-ray despite continuing symptoms, failing to obtain appropriate imaging, failing to call a surgeon, or misdiagnosing cecal volvulus as sigmoid volvulus.

A prior history of volvulus is another fact that should get a doctor’s attention.

These cases often come down to a timeline. When did the symptoms start? When did the patient arrive at the hospital? What did the imaging show? When was volvulus first suspected? When was a surgeon called? And what condition was the bowel in by the time surgery was finally performed?

If the bowel was still viable when the patient first presented but was necrotic by the time the correct diagnosis was made, that delay may be the center of the malpractice case.

Missed Volvulus and Other Medical Malpractice Claims in Maryland

If you or someone you love has suffered as a result of a medical misdiagnosis or failure to diagnose volvulus, call a Maryland attorney at 800-553-8082 or get a free online, no-obligation consultation.