Medicolegal aspects of Gastroenterology & Hepatology

1. Medicolegal aspects of Gastroenterology & Hepatology Dr Michael Glynn MA MD FRCP FHEA Consultant Physician and Gastroenterologist/Hepatologist Royal London Hospital - Barts Health NHS Trust National Clinical Director GI and Liver Diseases – NHS England – 2013-16 *

2. Basic GI Anatomy Oesophagus Stomach Small Bowel Large Bowel Liver Gallbladder and Biliary tree Pancreas.

3. Basic GI Anatomy

4. Some data: 1010 reports • 729 Gastroenterology (72%) (Clinical Nutrition 70) (Endoscopy 95) • 132 Liver disease (13%) • 147 Gen/Acute Medicine (15%) (Subarachnoid Haemorrhage 16) • 825 Claimant (81%) • 185 Others - defence and joint, coroner, employment, NHS Trusts.

5. Types of Cases • Clinical Negligence - Liability & Causation – or separately with the other being Surgical – causation after GP error • Personal Injury – abdominal trauma – trigger for Inflammatory Bowel Disease or Irritable Bowel • Life Expectancy - Inflammatory Bowel Disease – Liver Disease - Alcohol • Employment / Discrimination • Coroners cases

6. Gastroenterology topics (544) *Ulcerative Colitis 100 *Crohns Disease 98 *Post Surgical 42 Irritable Bowel 34 *Acute surgical 32 Gastroenteritis 28 *Colorectal cancer 25 *GI bleeding 23 *Clostridium Difficile 20 *Non-steroidal drugs 19 Pancreatitis 17 *Ischaemic bowel 13* *Oes/Gastric cancer 11 *Coeliac Disease 11 *Pancreatic cancer 9 Diverticulosis 8 Achalasia 5 Duodenal/gastric ulcer 5 *Radiation Enteritis 3 General Gastro 52

7. Ulcerative Colitis (100) • Acute Severe Colitis – delayed referral or delayed treatment – “could colectomy have been avoided?” • General quality of care • Onset after specific events (e.g. RTA) • Poor surveillance – interval cancer • Inadequate monitoring of treatment –Mesalazine and renal failure – Azathioprine and infection • Excess steroids and osteoporosis (Rheumatology) • Occasional fatality

8. Crohn’s disease (98) • Delayed diagnosis (but the norm is > 1 year) • Poor management • Delayed surgery – going on to perforation – “could surgery have been avoided?” – “could surgical complications have been avoided?” • Erroneous diagnosis • Occasional fatality

9. Acute Surgical and Post-surgical (74) • Surgical error – often delay in laparotomy for an acute issue – post-operative period is then complicated with infection and fistula • Issues of ‘short bowel’, malnutrition, bile salt malabsorption – often permanent situations with life changing effects • Occasional patient needing long-term intravenous feeding – major implications for life and cost

10. Colorectal Cancer (25) • Delayed diagnosis of the cancer • Poor follow up of colonic polyps • Causation usually needs Oncology opinion

11. GI Bleeding (23) • Poor management of acute GI bleeding • GI bleeding issues in acutely ill patients • GI bleeding issues and anticoagulation

12. Clostridium Difficile (20) • Delayed diagnosis • Failure to manage recurrence • Poor overall management – avoidance of surgery • Avoidance of C Diff – Micro/Infection Control • Antibiotic management - Microbiology

13. Non-Steroidal Drugs (9) • Failure to prescribe ‘gastro-protection’ (usually GP’s) – leading to bleeding or perforated ulcer

14. Ischaemic Bowel (13) • Patients presenting with acute bowel ischaemia (often fatal) • Could vascular issues have been detected earlier • Did the patient have true chronic mesenteric ischaemia • Would earlier treatment have avoided the acute event

15. Missed upper GI cancers (20) • Oesophageal– confusion with heartburn – genuine endoscopy delay or error • Gastric– confusion with dyspepsia– genuine endoscopy delay or error • Pancreatic – too much reliance on normal gastroscopy – delay in CT scan • All of these cancers have poor prognosis and so Causation (Oncology) is particularly important

16. Coeliac Disease (11) • Mostly overlooked GP results – sometimes years of delay • Causation issues (Oestoporosis)

17. Radiation Enteritis (3) • Unecessary Radiotherapy because of delayed (Gynaecological) cancer diagnosis • Bowel side effects – often severe, life changing and difficult to treat

18. Clincial Nutrition topics (29) General Nutritional care 23 Home Parenteral Nutrition 6

19. Clincial Nutrition topics • Difficult to be demonstrate that better nutrition would have altered outcome • Surgical complications – short bowel – Long term Home Parenteral Nutrition – life changing and very expensive

20. Liver topics (139) *Cirrhosis 40 *Hepatitis C 25 *Alcohol 23 Hepatitis B 12 Liver general 39

21. What is a Hepatologist? • All Gastroenterologists have liver training so as to cope with DGH liver disease • Hepatologists usually work in larger centres spending >50% of time doing liver disease • Some become pure Hepatologists - these tend to be regarded as ‘the experts’ but may be too specialised for general cases

22. Cirrhosis (40) • Delay in diagnosis – often Fatty Liver Disease – difficult to demonstrate that earlier diagnosis would have altered outcome • Poor management of complications (e.g. Ascites) • Late diagnosis of Hepatocellular Carcinoma – causation issues difficult • Poor surveillance for Hepatocellular Carcinoma – but overall poor outcome • The place of transplantation

23. Hepatitis C (25) • Delayed diagnosis – often for many years • Overlooked test result • Would earlier treatment have altered outcome • Hepatitis C curable from 2016/7

24. Alcohol (23) • Poor management of alcohol withdrawal • Wernicke’s Encephalopathy – delay in giving high-potency Vitamins (Pabrinex) • Central Pontine Myelinolysis– poor management of hyponatraemia • Life expectancy

25. Endoscopy topics (118) *ERCP 47 *Colonoscopy 27 *Percutaneous Endoscopic Gastrostomy (PEG)15 Endoscopy general 15 Gastroscopy (oesophageal perforation) 14

26. ERCP (47) • Highest complication rate of all GI Endoscopy • Was it indicated • Consent issues • Pancreatitis prevention (non-steroidal drugs) • Difficult to demonstrate poor technique (but operator data is helpful) • Were complications recognised and treated promptly

27. Colonoscopy (27) • Almost all are cases of perforation due to the procedure (1:1000 basic risk) • Was it indicated • Consent issues / trainee issues • Withdrawal of consent • Difficult to demonstrate poor technique (but operator data is helpful) • Were complications recognised and treated promptly (but surgery usually needed)

28. Percutaneous Endoscopic Gastrostomy (PEG)15 • Was it indicated • Consent issues • Difficult to demonstrate poor technique • Was long term care adequate (buried bumper) • Condition and Prognosis issues in neurologically damaged patients

29. Gastroenterology guidelines: • British Society of Gastroenterology www.bsg.org.uk • American Gastroenterological Association www.gastro.org • European Assoc for the Study of the Liver https://easl.eu • E Crohn’s & Colitis Organisation https://www.ecco-ibd.eu • Department of Health • NICE • (previous versions sometimes needed for more historic cases)

30. Associated experts: • GI surgeons (subspecialist) • Radiologists • Oncologists • Microbiologists • Intensivists • Pathologists

31. Medicolegal aspects of Gastro-Hepatology • Relatively few missed cancer cases • 20% about Inflammatory Bowel Disease • Relatively low numbers of Endoscopy complications • The standard messages are the same as expected:- • Basic clinical skills – history, diagnosis, management plan • Consent • Technical competence • Guidelines