Acute abdomen

A GP member responded to an early morning request to visit a male patient in his late 20's.

The patient had seen an out of hours doctor two days earlier complaining of abdominal pain and had been prescribed ranitidine. He felt no better and gave a history of sharp abdominal pain that started in the epigastric area and had now moved to the right upper quadrant. He had been vomiting intermittently but had no change of bowel habit.

The GP examined the patient, who was morbidly obese, and recorded tenderness in the right upper quadrant which was worse on inspiration. There were no other abnormalities on examination. The doctor's differential diagnosis was gallstones or dyspepsia that had not responded to ranitidine. He prescribed a proton pump inhibitor and analgesia and advised the patient to seek further advice in two days if his symptoms were not resolving.

Five days later the patient was admitted to hospital as an emergency, where he was noted to be cold, clammy and tachycardic with signs of an acute abdomen. He underwent emergency laparotomy and was found to have a perforated appendix stump and extensive peritonitis.

The patient's post-operative course was complicated by the development of an abscess, a wound infection and a small bowel fistula. He required admission to ITU and was an in-patient for several weeks.

He required admission to ITU and was an in-patient for several weeks.

The patient's claim alleged that the GP should have arranged immediate admission to hospital on the day of the home visit. If he had, it was claimed, the patient would have undergone surgery the same day and would have been an in-patient for only a few days.

The MDU obtained reports from a GP expert and a surgical expert. The GP expert advised that based on the doctor's account of his consultation, he was supportive of the doctor's management and denied that there had been any breach of duty. However, the expert did advise that if the court were to accept the patient's account of events that he was experiencing worsening abdominal pain then hospital admission should have been arranged.

The surgical expert found it difficult to speculate on exactly when the appendix had ruptured but thought that it had probably already ruptured at the time of the home consultation. However, he added that the patient's presentation was atypical and that the patient's obesity would have made it difficult to elicit the clinical signs. He further advised that if the member had admitted the patient to hospital, it is likely he would have proceeded to surgery either that day or the following day. However, he would still have required a laparotomy and on the balance of probabilities would still have developed the wound infection though not the small bowel fistula.

The claimant's experts were broadly of the same view. Although the claimant indicated that he wished to pursue the matter in court, the MDU legal team reasoned that because the case could turn either way on the factual evidence, there may be justification for negotiating a settlement. With the member's agreement, the team negotiated a vastly reduced settlement with no admission of liability.

Dr Louise Smy
Senior medical claims handler

This page was correct at publication on 04/12/2013. Any guidance is intended as general guidance for members only. If you are a member and need specific advice relating to your own circumstances, please contact one of our advisers.