Case 8 Irritable bowel syndrome after sickness in Goa

Alison, a 51-year-old English teacher, consulted Dr Chowdury following a holiday in Goa. Towards the end of her holiday she had colicky lower abdominal pain and on her return to the UK she had developed diarrhoea. Dr Chowdury arranged for stool cultures and reviewed her by phone one week later. The diarrhoea had not settled and Alison had noticed blood in the stool. The stool cultures were negative. Dr Chowdury referred Alison to the gastroenterologists to exclude inflammatory bowel disease. However the patient did not attend the appointment, presumably because her symptoms settled.

Alison consulted Dr Browne six months later. She was complaining of diarrhoea four or five times a day for the previous two weeks. She had intermittent lower abdominal pain but no blood or mucus in the stool. She had not lost any weight. Dr Browne noted that Alison had had an episode of diarrhoea the previous year and although referred had not been investigated. The diarrhoea seemed to be associated with stress at work. He also recorded that there was no family history of inflammatory bowel disease or colorectal cancer. He did not examine Alison because she looked well.

What would be your differential diagnosis?

Dr Browne organized blood tests, gave Alison a prescription for loperamide and arranged to review her in two weeks.

A computer entry one week later recorded normal FBC, U&E, LFT and glucose. The viscosity was 1.91 and the CRP 83. The result was actioned as ‘review as planned’.

Two days after the computer entry Alison attended a Walk in Centre because she felt worse. She had lost weight. The frequency of her diarrhoea had increased to 10 times a day and she had noticed blood in the stool. It was not clear whether she was assessed by a triage nurse or saw a doctor. An initial triage note recorded that Alison looked ‘pale and unwell’. Despite this a later consultation note recorded that she was ‘systemically well’, possibly because her temperature, pulse and blood pressure were normal. An abdominal examination was not performed. She was advised to see her own GP because of her persistent symptoms.

Alison returned to the practice for review three days later. She was seen by Dr White who noted a history of diarrhoea for two weeks with ‘blood in the motions’. On examination: PR 84; BP 128/80; soft abdomen but left iliac fossa tenderness. Dr White did not record that she had seen the raised viscosity or CRP. The diagnosis was ‘? colitis’. Stool cultures were arranged and Alison was prescribed ciprofloxacin and advised to continue loperamide. A review appointment was made for three weeks.

What would you have done differently?

Two days later Alison was admitted to hospital by the Out of Hours service. On admission she was extremely unwell and a diagnosis of severe ulcerative colitis with a toxic megacolon was made. Alison had a total colectomy with necrotic bowel. Her postoperative recovery was complicated by septicaemia. She was discharged six weeks later.

Alison sued the three general practitioners and the practice. She argued that she had not been properly assessed, that a differential diagnosis of inflammatory bowel disease should have been considered and that the practice had neglected to deal competently with her abnormal blood results.

Expert opinion

Acute diarrhoea is an extremely common presentation in general practice. The HPA defines acute diarrhoea as three or more episodes of loose stool a day for less than 14 days (HPA, 2010).

20% of the UK population experience gastroenteritis in any one year; 1 in 6 of those affected consults their GP (Wheeler et al., 1999). A study performed in the USA found gastroenteritis to be even more common, estimating 1.4 episodes of infective gastroenteritis per person per year (Herikstad et al., 2002).

The clinical features of infective gastroenteritis are abdominal pain, diarrhoea and vomiting. 76% of patients with infective diarrhoea no longer have symptoms after three weeks (Cumberland, 2003). The 1996 UK guideline on the management of infective gastroenteritis states: ‘Most episodes of infective gastroenteritis last for less than 14 days. The risk of an underlying non-infective diagnosis and the need for further investigation both increase if symptoms are prolonged’ (Farthing et al., 1996).

A competent general practitioner should take a careful history to elicit the duration and severity of the symptoms and the presence or absence of abdominal pain, nausea and vomiting, blood in the stool and weight loss. The examination should include an assessment of hydration, temperature, pulse, BP and abdominal palpation. It is generally only necessary to perform a rectal examination if there is rectal bleeding.

The vast majority of cases of infective gastroenteritis in adults require no investigation and no specific treatment other than advice about rehydration.

A review paper in 2009 in the BMJ on the management of acute diarrhoea (defined as diarrhoea lasting less than four weeks) makes the point that acute diarrhoea has a low predictive value for inflammatory bowel disease or colorectal cancer but that persistent symptoms merit prompt investigation (Jones & Rubin, 2009).

Red Flags would be:

• prolonged symptoms
  
• weight loss
  
• blood or pus in the diarrhoea
  
• prostration
  
• fever
  
• shock
  
• recent travel abroad
  
• recent use of antibiotics.

Most general practitioners would not carry out investigations such as stool culture or blood tests unless the diarrhoea is not abating after a week or there is blood in the stool.

Only 2–5% of stool specimens are positive and even if negative the diarrhoea may still be infective e.g. viruses, traveller’s diarrhoea (enterotoxic E. coli). For this reason the HPA recommends that stool samples are only required in certain circumstances (HPA, 2010). These include the ‘red flag’ circumstances.

Blood tests will normally consist of a CRP, ESR or serum viscosity (raised in bacterial gastroenteritis or inflammatory bowel disease), a full blood count, urea and electrolytes and liver function tests.

The actions of Dr Chowdury in 2008 are reasonable although some GPs might have reassessed Alison in the surgery and requested bloods. Presumably Alison did not attend the outpatient appointment because she was better.

When Alison was seen the following year she had already had symptoms for two weeks. Dr Browne recorded a careful history including the fact that Alison had had a similar episode six months earlier. Dr Browne should have measured a temperature, pulse and blood pressure and palpated the abdomen. However at this stage these would have been largely normal and the omission would not have affected outcome.

At this stage Dr Browne’s differential diagnosis should have included infective diarrhoea, anxiety/stress, inflammatory bowel disease (in view of the past history) and diverticulitis. Colorectal cancer, Coeliacs Disease and post-infective irritable bowel were other possibilities although the history was rather short. Alison was not noted to have features to suggest hyperthyroidism.

Dr Browne did not record a differential diagnosis. He organized appropriate blood tests although did not request antibody testing for Coeliacs Disease. Some general practitioners would have arranged a stool culture because of a two-week history of diarrhoea but this was not mandatory.

Dr Browne did record ‘very stressed’ and appears to have considered ‘stress’ to be a factor. He had not recorded a history that suggested irritable bowel syndrome (NICE, CG61). Irritable bowel syndrome can follow an episode of infective diarrhoea but the duration of the symptoms was too short to attribute the diarrhoea to this.

In hindsight Dr Browne’s choice of anti-diarrhoeal was unfortunate because loperamide can exacerbate inflammatory bowel disease and increase the likelihood of toxic megacolon. However, it is a standard treatment and the only thing which might have alerted him was the previous episode of bloody diarrhoea. Overall his actions were reasonable and although he did not examine Alison this would not have affected the outcome of the consultation.

A potential problem for the practice occurred when the results of the blood tests arrived. A CRP of 83 (and viscosity of 1.91) is high and suggests bacterial colitis or inflammatory bowel disease. The result needed to be considered carefully in the light of the previous history of bloody diarrhoea. The latter made it more likely that Alison had inflammatory bowel disease. Many general practitioners would have contacted Alison when the results were received, assessed her symptoms over the phone and arranged for a reasonably prompt review.

It is clear from the record of the Walk in Centre that Alison was quite unwell. Although she was later recorded as ‘systemically well’ she was initially noted to be ‘pale and unwell’. Alison had a three-week history of worsening diarrhoea which was now bloody, and she had lost weight. It is not clear who saw Alison in the Walk in Centre. If she was assessed by a nurse it would have been reasonable for the nurse to ask for an assessment by a doctor. In any event Alison should have had an abdominal examination and should have had blood tests taken. A competent general practitioner would either have arranged urgent blood tests or have sent her to A&E or the on-call medical team. When her inflammatory markers came back significantly raised she would have been admitted.

It would not be possible to defend Dr White’s actions. He recorded an inaccurate history and failed to note either the previous episode of bloody diarrhoea or the raised acute phase reactants. Alison must have clearly been unwell. Although a review was planned it was at too great an interval. Any safety netting would have included features that Alison already had. Alison should have been admitted to hospital.

Legal comment

We are told that Alison has sued three GPs – Dr Chowdury who saw her initially after her holiday in Goa, Dr Browne who saw her six months later, organized blood tests and arranged a review in two weeks and Dr White who saw her for review only two days before her colleague diagnosed severe ulcerative colitis and toxic megacolon. As indicated in the Expert Opinion, it will be difficult to defend the doctors’ standard of care.

We are told Alison has also sued the practice. The partners of the practice are jointly and severally liable for the negligence of each other. But most GPs have legal responsibility for their own errors, and will be indemnified by their MDO. Most partnership agreements make it a requirement that a doctor maintains MDO membership, so that the other partners have that reassurance. So if compensation has to be paid, the MDOs for the responsible doctors will pay for their individual liability. Those partners not responsible will not have to contribute to any settlement.

The blood test results should have prompted action. Is this the liability of the practice as a whole? The results should have been viewed by a GP, who should have initialled them. He or she will be responsible for this failure. If the doctor cannot be identified, then the practice as a whole will be held liable.

Dr White’s MDO appears to be the most exposed to this claim. He saw Alison two days before her collapse, when she was already seriously ill. Dr White may have a causation defence; in other words, he may be able to prove that intervention would have made no difference to the outcome. His MDO will instruct an expert to consider whether Alison required surgery anyway, regardless of Dr White’s negligence and how much worse her outcome was as a result of Dr White’s negligence, if at all.

It seems that for some reason Alison has not sued the Walk in Centre. The MDOs involved in this claim may well wish to seek a contribution from the Centre towards any damages.

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