TRAINING: The problems of emergency presentation with constipation – ‘half-job Harry rides again!’

Introduction

This article discusses the risk factors associated with the emergency presentation with constipation and how a careful history and examination with appropriate investigations are essential.

A case example

The patient, who was almost 80 years old, was seen in Accident & Emergency one afternoon with constipation. The history was not clear, and the examination was incomplete with the patient not lying flat to allow proper examination. The discharge diagnosis was constipation. The patient became unwell a few days later and deteriorated suddenly at home. They were readmitted but died shortly after admission. The post-mortem examination revealed that the cause of death was peritonitis due a perforation of an obstructing sigmoid colon cancer.

Independent recommendations to improve healthcare standards and patient safety

Diagnostic challenge

Diagnosis depends on history, examination and special investigations. In order to make a diagnosis, a proper history and examination are required to direct which investigations are required. Examination is not adequate without the patient being supine on a bed or trolley. A diagnosis of constipation was made. However, constipation is not a diagnosis but a symptom and therefore an explanation of the cause is required. The cardinal features of intestinal obstruction are nausea, vomiting and abdominal distension all of which were present.

A working diagnosis of intestinal obstruction is the logical outcome. This would mean that the ideal investigation is a CT scan of the abdomen and pelvis. It is true that some patients have renal problems that preclude the use of contrast. However, a non-contrast CT would have easily identified a cause.

If the patient is well enough then resuscitation and intestinal decompression are required. This would be followed by a laparotomy with either a Hartmann’s procedure or a sigmoid colectomy with a primary anastomosis possibly with a loop ileostomy. If the patient was not fit enough for a laparotomy or it is thought to be suitable, then a colorectal stent could be inserted, either as a bridge to resection surgery or for palliative care.

Preventing diagnostic error

• The problem in cases like this is that no adequate diagnosis was made. There is a character in medicine called ‘half-job Harry’ where only half of the job is performed and there as a result of an inadequate history and examination are performed then it is difficult to make a diagnosis.

• A diagnosis of constipation is inadequate. If the patient only has constipation and no other symptoms, then it would be reasonable to discharge the patient and arrangements made for the colorectal team to review the patient to establish a cause.

• If the patient has other symptoms. Especially those of intestinal obstruction, then urgent investigation is required, and this should be done on the day of admission if at all possible. The patient had the three cardinal features of intestinal obstruction.

Next Steps

It must be made clear in training that a careful history and explanation are required to stop falling into the ‘half-job Harry’ trap. It should be made clear that abdominal examination should be done with the patient lying supine on a trolley in A&E or on a bed on the ward.

Conclusion

The problem is that an inadequate history and examination was performed. The examination was not done with the patient supine. No diagnosis was made as constipation is not a diagnosis. No imaging was arranged despite the cardinal features of intestinal obstruction were present. Large bowel obstruction is a surgical emergency and the ACPGBI guidelines[1] are that urgent imaging such as CT is required and is the standard practice [2].

By raising awareness of the above issues, TMLEP aims to assist in developing guidance as to how the admission staff should be trained regarding history, examination (including pulse and blood pressure as dehydration and shock may be a feature) and making a differential diagnosis to identify what investigation is required to make an accurate diagnosis to allow appropriate treatment. If there is doubt, then the opinion of a surgical colleague should be sought as medicine is a team effort.