Setting the Scene
The patient in this case, attended A&E in 2011 with abdominal pain. An X-Ray showed dilated small bowel loops. When the patient reattended A&E the same year, they were diagnosed with worsening anaemia, although they were prescribed an iron replacement. The patient then underwent a gastroscopy which showed no abnormalities, but no faecal calprotectin test was undertaken. In 2014, the patient was found to have elevated calprotectin results which suggested possible intestinal inflammation. In 2015, a small bowel MRI scan was interpreted as normal, although there were clear features of distal ileal stricturing, which was associated with intervening mechanical bowel obstruction. In 2017, the patient reattended A&E and it was noted they had a number of episodes which led to hospital visits but no further small bowel imaging, either CT or MRI scan, was arranged until four months later. After reattending the patient’s GP and A&E on multiple occasions, they were diagnosed with Crohn’s disease in 2018. The main learning points from this review stem from the following events:
- A small bowel MRI scan was arranged four years after initial hospital visit.
- A colonoscopy was taken three years after it was first planned.
- The patient suffered with Crohn’s disease for seven years.
Recommendations to Prevent Incident Recurrence and Improve Patient Safety
TMLEP’s recommendations to reduce recurrence and enhance patient safety are as follows:
Anaemia and other symptoms suggestive of Crohn’s, should prompt further investigation by colonoscopy, MRI of the small bowel and faecal calprotectin. In this case, it is reasonable to suggest that had the patient undergone a small bowel MRI scan in 2011 and the MRI scan in 2015 been correctly reported, the condition would have been diagnosed earlier. It is recommended that should red flags of Crohn’s disease be viewed by clinicians, an investigation should be triggered, even if this is to rule out the diagnosis of Crohn’s. It is recommended that these investigations are followed through following guidelines in order to diagnose and treat the patient in a timely manner. In this case, a second small bowel MRI scan should have been arranged shortly after the 2017 appointment. Investigations which are not followed through can result in the patient repeatedly spending time at their GP surgery and in hospital with repeating symptoms.
- Clinicians should be mindful of the red flags of Crohn’s disease. This should include further education of signs to look out for when conducting scans and tests. In this case, the elevated calprotectin results are suggestive of possible Crohn’s disease. Other symptoms of Crohn’s disease include but are not limited to:
- abdominal pain
- fatigue (extreme tiredness)
- unintended weight loss
- blood and mucus in your faeces (stools)
- Anaemia or malnourishment
- Intestinal Inflammation
- Pallor, clubbing, aphthous mouth ulcers.
- Extra-intestinal manifestations, including abnormalities of the joints, eyes, liver, and skin.
- Although clinicians should be mindful that some patients may display alternative or less symptoms and Crohn’s should not be ruled out until there if definitive evidence.
In summary, Crohn’s disease affects 1 in 650 people in the UK with a bimodal age distribution. It is very common for Crohn’s to be diagnosed, with a median time of 1-2 years. A long diagnosis time puts patient’s safety at risk, as they are being forced to live with the condition uncontrolled for periods of time. It is recommended that investigations are undertaken to diagnose and appropriately treat the patients of their symptoms.
TMLEP would like to highlight the importance of recognising red flags of Crohn’s disease, following through with investigations and correctly reviewing tests. Signs of Crohn’s disease must not be ignored, and unexpected results should cause clinicians to consider re-testing or alternate investigations.