Cancer missed in patient with rectal bleeding
A 44-YEAR-OLD MAN went to his family physician, an internist, with complaints that included rectal bleeding. The physician performed a flexible sigmoidoscopy, which found hemorrhoids that weren’t inflamed or bleeding. A hemoccult test at a physical exam before the sigmoidoscopy was positive for bleeding.
A year later, the patient returned to the doctor complaining of blood in his underwear almost every other day. The doctor noted a “slightly inflamed hemorrhoid” on anoscopy, but no bleeding from the hemorrhoid; he didn’t test for occult bleeding.
Early the next year, the patient saw the physician for a complaint of blood in the stool and changes in bowel habits. A hemoccult test was positive, and the doctor diagnosed irritable bowel syndrome. The patient returned 6 months later with the same complaints and, he said, requested referral to a gastroenterologist. The doctor again attributed the complaints to irritable bowel syndrome.
Early the following year, the patient went to another internist because his insurance changed. This internist immediately diagnosed stage-3 rectal cancer. The patient underwent radiation, chemotherapy, and 2 surgeries, one to remove part of his rectum and a second to reverse an ileostomy done during the first operation. The patient was left impotent, with permanent, variable bowel dysfunction.
PLAINTIFF’S CLAIM: The diagnosis of hemorrhoids wasn’t reasonable; the patient should have been referred to a gastroenterologist or for colorectal cancer surgery. Early detection and diagnosis would have resulted in removal of a polyp or early cancer, which could have been done during a colonoscopy or by transanal excision.
DOCTOR’S DEFENSE: The patient’s doctor denied that the patient had requested a referral to a gastroenterologist and maintained that he believed the flexible sigmoidoscopy had ruled out a serious cause of bleeding.
VERDICT: $1 million Virginia verdict.
COMMENT: When a patient has persistent rectal bleeding without a clear cause, no matter what the patient’s age, further evaluation or referral is prudent.