Persistent dyspepsia

...Mr K again complains of indigestion and stomach pain and he is referred for rapid access endoscopy...

Day 1

Mr K is a 73-year-old retired taxi driver and presents at his local GP surgery complaining of stomach pain. He sees Dr L who records “epigastric pain, some relief from OTC (over the counter) antacids, feels lethargic, check FBC (full blood count)”. The GP prescribes omeprazole for the patient and asks him to return in two weeks.

Day 23

A health check at his pharmacy finds Mr K’s blood pressure is raised so he attends the surgery and is treated by Dr B. He finds the patient’s BP is slightly elevated and discusses adjusting his hypertension medication dosage. He asks Mr K again about the stomach pain but is told it’s been “no real bother”. Dr B informs him his latest blood test was normal.

Month 3

Mr K attends the surgery for a lingering chest infection. He is seen by Dr L who prescribes amoxicillin. Again there is no further mention of stomach pains or indigestion.

Month 4

Mr K returns a month later to Dr L, concerned about an elevated reading from his home BP monitor. The only note made for this visit states “BP 150/82” but the practice system shows that ranitidine, 150mg tablets, twice daily, was also prescribed. This suggests a return of the epigastric pain Mr K complained of a few months ago.

Month 6

Mr K returns again complaining of recurring indigestion and stomach pain. He sees Dr B who notes the patient is now also reporting early satiety at meal times, loss of appetite, and weight loss. He has vomited a few times but with no haematemesis. Dr B finds epigastric tenderness on examination but no abdominal masses. Mr K is referred for “rapid access” endoscopy.

Month 6

A week later a hospital endoscopy on Mr K reveals two ulcers and nodular mucosa at the gastrooesophageal junction with biopsies showing “no evidence of dysplasia or malignancy”. A CLO test is positive for H. pylori and Mr K then attends the GP surgery and is prescribed “triple” eradication therapy (lansoprazole, amoxicillin, clarithromycin).

Month 19

The consultant requests a review endoscopy for three months later but an admin error causes a 10-month delay. Afterwards the nurse endoscopist reports moderate atrophic gastritis and a deformed pylorus which is difficult to enter. A gastric biopsy finds poorly differentiated adenocarcinoma. A CT scan and laparoscopy confirm a gastric antral tumour.

Month 31

Mr K dies in hospital of metastatic gastric carcinoma.

 

SIX MONTHS later solicitors representing Mr K’s widow lodge a clinical negligence claim against Dr L for failure to timeously refer the patient for suspected stomach cancer.

MDDUS instructs two experts to provide opinions – a primary care physician and a consultant histopathologist. The primary care expert is critical of aspects of the first consultation with Mr K in regard to the patient records. Dr L did note the reported epigastric discomfort but did not record whether he had asked how long the pain had been present, precipitating factors, any loss of appetite or weight, eating or swallowing problems. There is also no record of an abdominal examination.

NICE guidelines call for urgent referral of patients over 55 years of age with unexplained or persistent recent-onset dyspepsia and particularly with dysphagia, vomiting, abdominal pain and weight loss. But the expert does not feel that this description strictly applied to Mr K in the first consultation with Dr L.

In regard to the later consultation that resulted in a ranitidine prescription – the expert feels this is clear evidence of persistent dyspepsia but there is nothing in the records to indicate how this was assessed via history and examination. In his opinion this consultation and the failure to refer the patient for an urgent endoscopy fell below an expected standard.

The expert histopathologist re-examines the tissue samples provided from the gastric and oesophageal biopsies taken in the first and follow-up endoscopies. In his opinion the first biopsy showed severe helicobacter-associated gastritis but also contained several groups of “rather bland cells suggestive of adenocarcinoma” which appear to have been missed by the reporting histopathologist, though he acknowledges identification can be difficult. The subsequent administrative scheduling error in the follow-up endoscopy led to an even further delay in diagnosis.

In the end the case against the GP – Dr L – was discontinued but a separate claim against the hospital was settled out of court.

KEY POINTS

• Record all key findings in history and examination to justify clinical decisions.

• Ensure consideration of best practice guidelines in clinical decision-making.

• Have a low index of suspicion in elderly patients with persistent and unexplained dyspepsia.