Post Colonoscopy Bleed: Negligence or Not?

Case history

The patient had undergone coronary stenting in November 2002 and he was taking aspirin, clopidogrel and metoprolol. The surgeon performed a proctoscopy which revealed large haemorrhoids. These were treated by banding. The surgeon also recommended that the patient undergo a colonoscopy and this was booked to be performed three weeks later. 

During the consultation, the surgeon informed the patient that if he had any polyps, the surgeon may need to perform a biopsy. The surgeon told the patient that colonoscopy was a safe procedure but there was a small risk of perforation of the bowel and bleeding in the order of 1 in 2,000 cases and also a risk of bleeding from the biopsy of any polyps. He provided the patient with a brochure which included the comment that colonoscopy ‘is very safe although there is an extremely small risk of bleeding or perforation of the bowel, particularly if a polyp is removed and also an extremely small risk of missing a significant pathology’. 

The surgeon was aware when he recommended a colonoscopy that the patient was taking anticoagulant medications, namely aspirin and clopidogrel. He did not advise the patient to stop these medications before the procedure. He felt that the colonoscopy had such a small risk of bleeding that he did not consider such a risk warranted ceasing the anticoagulants before the performance of the procedure. 

The colonoscopy was performed on 4 March 2004. This revealed acute proctitis extending for approximately six centimetres above the mucocutaneous junction. The surgeon felt this was consistent with ulcerative colitis. A tiny sessile polyp was found in the ascending colon. The surgeon ‘hot’ biopsied the polyp and also took four pieces of tissue from the suspected area of ulcerative colitis. The biopsy from the polyp was 3x2x2mm and the four other pieces of biopsied tissue were of like size. The patient was discharged home with a letter outlining the findings at colonoscopy and including the advice ‘it is possible that bleeding can occur up to one week after the procedure and removal of a polyp’.

No evidence of dysplasia or malignancy was detected on histopathology of the polyp. The other biopsies were consistent with a diagnosis of ulcerative colitis.

Nine days later, on a Saturday afternoon, the patient’s wife phoned the surgeon and informed him that the patient had ‘passed a lot of blood’ and he was feeling dizzy. The surgeon recommended rest and suggested the patient be reviewed in a couple of hours. 

The patient continued to experience further heavy bleeding and he was taken by ambulance to hospital. The patient required a number of blood transfusions in view of his low haemoglobin and ongoing PR bleeding. 

On 15 March 2004, an angiogram was performed which demonstrated that the source of the bleeding was the right side of the colon. A right hemicolectomy was performed on 16 March 2004. The site of the biopsied polyp was identified as the source of the bleeding.

In March 2007, the patient commenced legal proceedingsagainst the surgeon.

Medico-legal issues

The allegations against the surgeon in the Statement of Claim were that he was negligent in:

• failing to investigate the patient’s tendency to bleeding by taking a more detailed history and blood coagulation tests;
• failing to heed the fact that there was a strong possibility that a polypectomy might be required as part of the colonoscopy;
• disregarding the risk of bleeding following colonoscopy and polypectomy;
• disregarding the fact that the patient was taking aspirin and clopidogrel that affected platelet function and/or led to an increased risk of bleeding;
• failing to make any adequate inquiries of the patient’s cardiac problems and/or treatment; and
• failing to instruct the patient to cease his aspirin and/or clopidogrel prior to performing the colonoscopy and polypectomy, in particular at least 14 days prior to the procedure.

The patient claimed to have suffered an unnecessary hemicolectomy and depression as a result of the surgeon’s negligence.

The patient served an expert report by a surgeon with the Statement of Claim. The report stated that a detailed history relating to a past history of a ‘bleeding tendency’ and “blood coagulation tests’ should have been performed” . The surgeon stated that colonoscopic polypectomy carried a small but definite risk of bleeding as a complication of between 0.2 – 1%. In this case, ‘there was a strong possibility that polypectomy might be required as part of the procedure.

With regard to the patient’s medication, the expert surgeon stated that the generally accepted recommendation is that drugs affecting platelet function should be ceased 10 to 14 days prior to elective surgical operations. He opined that the defendant surgeon ‘should have taken the patient off the aspirin and clopidogrel and/or consultation with the patient’s cardiologist would have been appropriate’. He went on to state that ‘for those patients in which cessation of anticoagulants poses a risk, the procedure may be performed without the anticoagulants being ceased provided the patient is informed of the additional risk of bleeding and the advice of a haematologist is obtained in case there is intra or post procedure bleeding’. If these steps had been taken, the expert surgeon opined that the patient would not have developed post-polypectomy bleeding; or alternatively, if such bleeding did occur, it would not have been so persistent.

Expert opinion was obtained on behalf of the defendant surgeon. The surgical opinion concluded that the colonoscopy was appropriately indicated, given the patient’s history of rectal bleeding and his age. The expert noted that the defendant surgeon was aware that the patient was on aspirin and clopidogrel and he decided not to advise that these medications be ceased prior to the colonoscopy. The expert concluded that ‘in my opinion, that decision was appropriate. Aspirin and clopidogrel are synergistic anti-platelet medications given to reduce the risk of thrombotic events in susceptible patients. Both drugs have to be stopped for at least a week or possibly ten days before their effects are fully reversed. The decision on whether or not to suspend anti-platelet medication therefore depends on balancing the potential risk of bleeding from the surgical procedure versus the risk of a thrombotic episode while the medication is suspended. There is no general agreement among endoscopists about whether such medication should be stopped prior to colonoscopy and/or biopsy. The patient’s post-colonoscopy bleeding was a rare and unexpected event. It was also unusual that it was delayed for nine days after the biopsy. In most patients, a small biopsy, as in the case of this patient, is completely healed by that time and most post-polypectomy bleeding presents in the first few days after colonoscopy’. The expert noted a Mayo Clinic study which concluded that there was no significant difference in aspirin use between those patients who presented with post-polypectomy bleeding and those who did not.

He also reported that the American Society for Gastrointestinal Endoscopy guidelines concluded that, in the absence of a pre- existing bleeding disorder, endoscopic procedures may be performed on patients taking aspirin in standard doses.

This expert report was served on the patient’s solicitors with a request for a discontinuance of the claim against the surgeon, on an own costs basis (each party to bear their own legal costs). Some months later, this offer was accepted by the patient’s solicitors.

Discussion and risk management strategies

This claim highlights the importance of discussing the benefits and risks of procedures with patients as part of the consent process, especially taking into account the particular circumstances of the patient; in this case, his anticoagulant medications. The defensibility ofthis claim would have been assisted by specific documentation of this discussion and the consideration of the anticoagulant medications by the defendant surgeon. 

Also, it was apparent that the patient felt he had been neglected and abandoned by the surgeon when he experienced the post colonoscopy bleeding. The patient reported that when his wife rang the surgeon to inform him about the significant bleeding, the surgeon said that he was playing golf and implied that she was being a nuisance in contacting him. The patient also claimed that the surgeon never rang back to check on his condition, nor did he contact or visit him during his four week stay in hospital, despite the surgeon being on staff at the hospital. 

A 1994 study which examined the reasons why patients sued their  doctors revealed that 71% of the claims involved ‘problematic relationship issues’, specifically:

1. deserting the patient (32% of claims)
2. devaluing the patient and/or family views (29% of claims)
3. delivering information poorly (26% of claims)
4. failing to understand the patient and/or family perspective  (13% of claims)¹.

In view of the low potential quantum of this claim (less than $100,000), the patient’s perception of having been abandoned and deserted by the surgeon following the complication of the colonoscopy, may have contributed to the patient’s decision to commence legal proceedings.

Reference

1. Beckman HB, Markarkis KM, Suchman AL, Frankel RM. The Doctor-Patient Relationship and Malpractice: Lessons From Plaintiff Depositions. Arch Intern Med 1994;154:1365-1370.