Medical Malpractice Insights: Bowel perforation due to stercoral ulcer

Here’s another case from Medical Malpractice Insights – Learning from Lawsuits, a monthly email newsletter for ED physicians. The goal of MMI-LFL is to improve patient safety, educate physicians and reduce the cost and stress of medical malpractice lawsuits. To opt in to the free subscriber list, click here.

Chuck Pilcher, MD, FACEP

Editor, Med Mal Insights

Bowel perforation due to stercoral ulcer (but you knew that)

Good documentation prevents lawsuit

Facts: A 56-year-old female is brought to the ED for “shaking” at home and being weak “like a ragdoll.” Her husband believes this is related to her opioid medications taken in high doses for chronic back pain. The family reports poor PO intake and a 20-pound weight loss in the past month, but the patient herself is not concerned. She has not had a bowel movement in several days. Review of systems is positive for subjective fever and pain in the chest, back, and abdomen. Exam reveals abdominal distention and mild generalized tenderness. An abdominal x-ray reveals constipation. A drug screen is positive for opiates. Hydromorphone level is 2593 (therapeutic <199). Hydrocodone level is 6446 (therapeutic <99). The latter correlates to an intake of 30-105 mg of hydrocodone in the previous 3-7 hours. A CBC is remarkable for a WBC of 11,500 with 31% bands. She is treated with IV fluids and pain meds. Despite the band count, she is believed to be stable for discharge following evaluation. The family agrees that she will be safe at home and will follow up with her PCP in the next 1-4 days. Discharge diagnosis is “constipation,” “failure to thrive,” and “dehydration.” Three days later she is admitted to a different hospital with a bowel perforation and sepsis. Surgery finds a large “stercoral ulcer” of the proximal sigmoid colon with disseminated pus. [Editor’s Note: A stercoral ulcer is an ulcer of the colon due to pressure and irritation resulting from severe, prolonged constipation due to large bowel obstruction. It is most commonly located in the rectum.] She expires 10 days later. The family consults an attorney.

Plaintiff:  You should have discovered how sick I was on my first ED visit. My band count indicated I had a major infection, and you made no mention of it your medical decision making (MDM). High dose opioid use is associated with constipation, and prolonged constipation causes stercoral ulcers, and stercoral ulcers often perforate.

Defense: You had no fever. Your x-ray showed only constipation with no free air. Your abdomen was only slightly tender, and you weren’t even complaining about it. You improved in the ED, and both you and your family were comfortable with you going home and seeing your PCP about your overuse of opioids. And stercoral ulcers are rare.

Result: An ED expert found the chart very well documented with an appropriate differential ruling out appendicitis, sepsis, or other serious abdominal pathology. The elevated band count was concerning and not specifically addressed, but that one fact amidst significant evidence of thoughtful, well-documented care was felt to be insufficient to prove medical negligence. No lawsuit was filed.

Takeaways:

• “Stercoral ulcer” of the colon should be considered in all patients with abdominal pain and chronic constipation from any cause. It is most common in heavy users of narcotic medications. Such ulcers often perforate with disastrous results.
• An elevated band count, especially 31%, should raise huge red flags and should always be addressed in one’s medical decision making, especially if one is planning to ignore it and discharge a patient home. [See reference below.]
• Otherwise excellent documentation resulted in a bullet dodged.
• The patient’s opioid addiction, contributory negligence, improvement in the ED and the family’s wish to take the patient home likely contributed to the attorney’s decision not to pursue a lawsuit.
• Check all labs and address the abnormal ones.

References:

1. Stercoral Ulcer: Definition. Free Medical Dictionary.https://medical-dictionary.thefreedictionary.com/Stercoral+ulceration
2. Stercoral Ulcer: Mumford JG. Boston Med Surg J [now NEJM] 136:129-131. February 11, 1897. nejm.org/doi/full/10.1056/NEJM189702111360604
3. Bandemia with normal white blood cell counts associated with infection. Drees, M et al. Am. J. Med 2012 Nov;125(11):1124.e9-1124.e15.https://pubmed.ncbi.nlm.nih.gov/22939096/