This case involves an elderly female who had been a resident in a nursing home for several months before the events of the incident in question. The patient had recently become bedridden due to an unrelated illness, and it was the responsibility of nursing staff to monitor the patient. Despite this, the patient was left unattended for almost two weeks, during which time she only had one bowel movement. Eventually, the patient was discovered by nursing home staff and was brought to the emergency room. While in the hospital, doctors noted that the patient was suffering from pressure ulcers, acute respiratory insufficiency, septic shock, and gastroparesis.
Question(s) For Expert Witness
- 1. Do you routinely treat patients with gastroparesis?
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2. How few bowel movements a day/a week should raise concern to health workers in a patient like this?
Expert Witness Response E-096088
I routinely treat patients with gastroparesis in both inpatient and outpatient settings. This includes diagnosing gastroparesis; treating gastroparesis with medications and dietary strategies, and identifying/managing complications associated with gastroparesis. In terms of stool frequency, the Rome III criteria defines constipation as having less than 3 bowel movements per week. Accordingly, patients meeting this criteria should raise health workers’ concern for constipation. However, patients with constipation can routinely skip several days between movements without any severe complications. Having one bowel movement in 12 days is consistent with severe constipation or a fecal impaction. The frequency of the stool is not the only characteristic that raises the concern for constipation. Stool hardness, abdominal pain, bloating, passing flatus, and straining are other characteristics worth considering. I have seen feculent vomiting in patients with bowel obstructions, but not simply constipation. It is possible to have a large bowel obstruction from a fecal impaction. A review of imaging studies is required to identify if a bowel obstruction or fecal impaction lead to his feculent vomiting.
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