When Severe Abdominal Pain Does Not Match the Exam

Description

A high-risk patient with untreated atrial fibrillation presented with classic ischemia warning signs, but delayed escalation to CT angiography and surgical evaluation led to bowel necrosis, extensive resection, and lifelong complications.

Key Lessons

• Failure to act on red flags: Severe abdominal pain out of proportion to exam in a patient with atrial fibrillation/vascular risk plus a rising lactate should have triggered high suspicion for acute mesenteric ischemia and immediate escalation.

• Delay in definitive diagnosis and specialty response: CT angiography and timely in-person surgical/vascular evaluation were deferred despite clinical deterioration, allowing progression to extensive bowel necrosis and life-altering complications.
• Escalation and documentation gaps: When the patient worsened, communication/ownership for urgent imaging and consultant follow-through was unclear; lack of closed-loop escalation and clear documentation increased medicolegal vulnerability.

Clinical sequence

A 67-year-old man with chronic atrial fibrillation (not on therapeutic anticoagulation), hypertension, and peripheral vascular disease presented to the emergency department with abrupt onset of severe, diffuse abdominal pain and nausea that began approximately 1 hour after breakfast. He was afebrile with mild tachycardia and a relatively benign abdominal exam (minimal tenderness, no guarding).

Initial labs showed leukocytosis and an elevated lactate of 3.2 mmol/L, which increased to 5.1 mmol/L after fluid resuscitation. A contrast-enhanced CT of the abdomen and pelvis (without arterial phase/angiography protocol) was interpreted as showing nonspecific bowel wall thickening and possible enteritis.

The patient was admitted to the medicine service for pain control and serial exams. A surgical consult was requested by phone; recommendations included continued resuscitation and reassessment, with consideration of further imaging if symptoms persisted.

Over the next several hours, the patient continued to report severe pain out of proportion to exam and required increasing opioid doses. Repeat labs demonstrated a rising lactate to 7.0 mmol/L with evolving metabolic acidosis. Nursing documentation noted persistent severe pain and declining urine output, with repeated notifications to the primary team.

Escalation to CT angiography and in-person surgical or vascular evaluation was discussed but deferred, with concern for cumulative contrast exposure following the earlier CT and a plan to continue monitoring and reassess clinically. Additional pages to the consulting surgical service were documented, but no in-person evaluation occurred during this period.

By the following morning, the patient developed hypotension and new peritoneal signs. CT angiography was obtained emergently and demonstrated an occlusion of the superior mesenteric artery with poor distal perfusion. Vascular surgery and general surgery were consulted urgently, and the patient was taken to the operating room for exploratory laparotomy with attempted thrombectomy and bowel assessment.

Intraoperatively, extensive small bowel ischemia was identified, requiring resection of the majority of the jejunum and ileum, along with partial colectomy. The patient survived but was discharged with an ostomy and subsequently developed short bowel syndrome, requiring prolonged total parenteral nutrition, multiple readmissions for dehydration and catheter-related complications, and significant functional decline.

Allegation

The plaintiff alleged a failure to timely recognize and treat acute mesenteric ischemia, including failure to obtain emergent CT angiography despite persistent pain out of proportion to exam and rising lactate, and failure to secure timely in-person surgical/vascular evaluation and operative intervention. The alleged delays were claimed to have resulted in avoidable progression to extensive bowel necrosis, short bowel syndrome, and long-term dependence on parenteral nutrition with recurrent hospitalizations.

Disposition

The case resolved via settlement in the multi-million dollar range.

Clinical Analysis

Failure to prioritize a high-risk diagnosis

• Atrial fibrillation without therapeutic anticoagulation plus vascular disease created a strong risk for embolic mesenteric ischemia
• This risk profile was not sufficiently integrated into early clinical decision-making

Classic red flags not acted upon

• Persistent pain out of proportion to exam and escalating opioid requirements are hallmark early signs
• Ongoing severe symptoms over several hours did not trigger urgent diagnostic escalation

Overreliance on nondiagnostic imaging

• Initial CT without arterial phase has limited sensitivity for mesenteric ischemia
• Nonspecific findings contributed to diagnostic anchoring and delayed reconsideration

Delayed escalation despite worsening objective data

• Rising lactate and developing metabolic acidosis indicated progressive ischemia
• These trends did not prompt timely CT angiography or higher-level intervention

Inadequate specialty escalation

• Surgical input remained remote despite clinical deterioration
• Lack of timely in-person surgical/vascular evaluation contributed to missed opportunity for earlier intervention

Discussion Questions

1. At what point does “reassurance” from initial tests become a liability, and how can clinicians recognize when they are being falsely reassured?
2. How do hierarchy, workflow, or overnight coverage models influence whether concerns (e.g., from nursing or consulting teams) translate into action?
3. If this patient had presented differently, for example, with less classic symptoms and normal lactate, what safeguards should still be in place to avoid a similar outcome?

Related Resources

• Acute Mesenteric Ischemia in the ED: Diagnosis and Treatment
• Acute Mesenteric Ischemia Treatment & Management: Approach Considerations, Initial Resuscitation and Stabilization, Pharmacologic Therapy

This is a fictitious case that illustrates commonly encountered issues and is for educational purposes only. Any resemblance to real persons, living or dead, is purely coincidental.