CASE IN POINT

COLONOSCOPY MISSED LESION?

In February of 2004, a 57-year-old African-American woman went in for an elective colonoscopy. She had some abdominal pain and changes in her bowel habits consistent with long-standing irritable bowel syndrome. Overall, the colonoscopy was normal. A small sessile growth at the rectum was removed and diagnosed as being benign, non-polypoid tissue. The cecum was listed as normal (Fig 1-1).

Fig 1-1 --- Click on Images to Enlarge
In February of 2007, she again came in with abdominal pain and functional bowel disease. She had another colonoscopy, which was unremarkable (Fig 1-2).
Fig 1-2
In September of 2011, for the first time, she presented with anemia and weight loss, and had another colonoscopy, which showed a flat lesion above the ileocecal valve that unfortunately was malignant (Fig 1-3).
Fig 1-3

PLAINTIFF'S CLAIM:

The defendant missed the lesion on the earlier colonoscopy in 2007. Based on tumor doubling times, it was present and should have been caught earlier for better chance of survival (Fig 2-1).

Fig 2-1

PORTIONS OF THE DEFENSE'S ARGUMENT:

The tumor was not visible on the 2007 colonoscopy. The tumor was a flat lesion that was very aggressive, with growth down through the colon wall to the lymph and blood vessels (rather than upward into the lumen). Even if the tumor was present during the 2007 colonoscopy, it was unlikely to be large enough to be seen.

VISUAL STRATEGY:

Collaborating with the defendant and defense attorney, Illustrated Verdict created a visual strategy to help illustrate what the doctor had seen, using photographs taken during the colonoscopies.

Illustrated Verdict selected an overview of the anatomy to help orient the jury to the colon. (Fig 4-1)

Fig 4-1

 

We created an illustration of a cross-section of the colon and the colon wall.
(Fig 4-2)

Fig 4-2
 

We also created a board showing how a colonoscopy is performed.(Fig 4-3)

Fig 4-3
 

This board demonstrating how a flat lesion can grow deep and not be seen on the surface shows what happened in this case. (Fig 4-4)

Fig 4-4
 

In this board, cancer cell growth rate shows how quickly cancer can grow over doubling times. (Fig 4-5)

Fig 4-5
 

The following three boards mapped the patient's actual colonoscopy photos to where in the colon they were taken during the three different colonoscopies. (Fig 4-6, 4-7, 4-8)

Fig 4-6
Fig 4-7
Fig 4-8
 

The illustrations helped the defense successfully convey to the jury the following key points:

  • Unfortunately, the nature of the lesion, flat with outward growth, made detection hard with a colonoscopy.
  • The photos of the colonoscopies clearly showed that there was no lesion in 2007, when directly compared with 2011.

 

 

 

RESULT:
The case was favorably resolved. 

"The illustrations were great, particularly the ones correlating the anatomy with the colonoscopy photographs. Indeed, by the end of plaintiff's case, plaintiff's expert agreed there was no lesion present in 2007. The illustrations made a real difference. Thanks very much."

- Attorney Donna Zito, O'Brien, Tanski & Young LLP, Rocky Hill, CT

 

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