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Medico Legal Aspects of Gastroenterology

Medico Legal

by Dr Gerry George Robins Consultant Gastroenterologist FRCP Lond, MD, MBBS


A healthy gastrointestinal system is something that many of us take for granted, and only when it goes wrong do we realise the impact on quality of life, family and employment. Gastrointestinal disease is traditionally something that we in the UK are not very good at talking about, yet in the UK gastrointestinal disease is the third most common cause of death, the leading cause of cancer death and the most common cause of hospital admission (gastrointestinal disease is estimated to be responsible for 1 in 6 admissions to hospital in the UK.

Clearly there are many different types of gastrointestinal disease, and in the field of medicolegal work, first thoughts often turn to abdominal and biliary surgery and its potential complications. However, in the non-surgical field of gastrointestinal disease (Gastroenterology) there is a significant burden of disease, often chronic, which can be overlooked. For example, the Irritable Bowel Syndrome (IBS) is estimated to affect 10 to 25% of the general UK population (with the prevalence in women being between 2 to 4 times greater than in men) and about half of patients with IBS will present to their GP because of symptoms. There is very clear evidence that stress, both acute and chronic, will both precipitate and exacerbate IBS, although the mechanism is not fully understood. There have been numerous trials looking into putative mechanisms, and there is clear data showing that in individuals with IBS who experience stressful or anxiety inducing events, there are changes in the inflammatory profile of both the gut and central nervous system, changes in the endocrine profile of the affected individual (e.g. levels of hormones such as corticotropin and melatonin alter) and also in the bacteria that live within the gut, to name just a few possible mechanisms. Clearly it is entirely plausible that a different mechanism predominates in different individuals, and that there may be multiple mechanisms at work within the same individual. Prognosis in patients with IBS is variable, and compared to healthy controls, patients with IBS are often documented to have extra-abdominal symptoms (e.g. insomnia, sexual dysfunction, urinary symptoms and headache), significantly reduced quality of life, difficulty socialising, reduced participation in sport and travelling and increased absence from work, with a significantly reduced length of working life (with the associated financial implications consequent upon this).

From a medicolegal perspective these facts are important considerations in Claimants who have either developed IBS or had a worsening in their pre-existing IBS symptoms due to a significant life event. Significant life events often precipitate the need for a medicolegal opinion in their own right (e.g. road traffic accident, medical negligence, wrongful dismissal) but the effect on underlying pre-existing, or new, gastroenterological conditions is often overlooked by Claimant’s lawyers when considering all aspects of the case. In other circumstances Claimants who already suffer with IBS may not get the recognition they need from their employer with regards to making appropriate reasonable adjustments within the physical environments of their workplace, and the nature of the work expected to be undertaken. Often patients with IBS need only a relatively small change in work practice to allow them to continue to be productive members of the work team. Simple examples of changes employers could make include allowing the Claimant to come into work an hour or two later (patients with IBS often have worse symptoms first thing in the morning), allowing more working at home (so patients have ready access to their own toilet facilities) and minimising the need for long work-associated periods of travel. The assumption by employers and others that “it’s just IBS” and such patients are exaggerating the impact of their disease on their ability to work, completely underestimates the severity of symptoms that some patients with IBS can have - these symptoms need to be taken seriously.

As IBS is so prevalent another potential mishap is the misinterpretation by a medical practitioner of the development of new symptoms within a patient as heralding the onset of IBS, when in fact the development of new symptoms such as bloating, change in bowel habit, or non-specific abdominal pain is the manifestation of a significant organic disease such as bowel cancer, ovarian cancer or coeliac disease. Occasionally symptoms that should never be interpreted as IBS, are - with potentially significant consequences. Examples of such symptoms that at least initially should not be assumed to be due to IBS include nocturnal symptoms, weight loss, persistence of symptoms despite evacuation of stool, and rectal bleeding. There are very well defined criteria for diagnosing IBS (Rome III criteria) and IBS should always be a “positive” diagnosis and simply not a label given to a patient because their symptoms do not sound like another problem.

In addition to chronic diseases such as IBS, there are acute gastroenterological diseases, which may warrant consideration of a medicolegal opinion. One of the most common scenarios in this group is travel-associated gastroenteritis or traveller’s diarrhoea. In those travelling abroad, especially to countries with a low GDP, it is estimated between 20% and 60% will experience at least one episode of diarrhoea. Whilst usually a self-limiting illness, and rarely life-threatening traveller’s diarrhoea often affects enjoyment of holiday for both the individual affected and other family members and friends in their travelling group. For many families, holidays abroad represent an investment of a significant amount of their disposable income and notwithstanding the unpleasantness of the ongoing symptoms, the need to spend a significant period of time in one’s hotel room unable to participate in activities and/or relaxation is a source of frustration for many people in this circumstance. Often symptoms will continue for a period of time after return to the UK (1 in 20 patients will have symptoms lasting longer than 2 weeks), with Claimants having to miss time off work and reduced other activities for days to weeks afterwards. A causative organism for traveller’s diarrhoea is not identified in up to 70% of cases (as many cases are due to viruses such as norovirus, and many people often do not submit a stool sample), but in those cases where a pathogen is identified, E.Coli is the most common culprit. Destinations considered high risk for traveller’s diarrhoea include South America, Sub-Saharan Africa and South and South East Asia. All inclusive holidays (including cruise ships) and backpacking are also known to increase the risk of developing traveller’s diarrhoea. Typically, episodes of traveller’s diarrhoea start during the first week of travel with most episodes lasting approximately 7 days. A few examples of warning signs for Claimants that hotels or cruise ships may be breaching their duty of care with regards to providing safe food and drink include continually reheating food, serving or handling uncooked food and cooked food together, not serving food at a correct temperature (either not hot enough or not chilled enough), staff handling food not wearing gloves, the presence of animals and insects around eating areas and serving drinks that are watered down or have ice in.

Whilst acute diarrhoeal illnesses are also common in the UK, they do predominate in settings with high levels of contact and potentially compromised hygiene, such as hospitals and nursing homes. Norovirus is the most common cause of outbreaks of infectious diarrhoea in hospitals. This is generally self- limiting and introduced from the community into the healthcare setting through infected patients, visitors and staff (often in the asymptomatic phase of the disease). Clostridium difficile however, whilst a component of the normal gut bacteria of between 3% to 10% of the adult population, is a bacteria that causes a diarrhoeal illness that is one of the most prevalent problems in UK hospitals. The incidence of Clostridium associate diarrhoea increased 4-fold between 1999 and 2004. Prolonged hospitalisation and repeated courses of antibiotics are significant risk factors for developing Clostridium difficile associate diarrhoea. This means it is more likely to be seen in people who are undergoing a complicated recovery from many medical and surgical problems – as by definition this group will very often have a prolonged stay in hospital and often need prolonged and repeated courses of antibiotics. Clostridium difficile associated diarrhoea can evolve into a more severe form of pseudomembranous colits, which in turn can be life threatening and Clostridium difficile infection per se is associated with significant morbidity and
mortality. Again, in medicolegal cases, where the sum total of harm done to the Claimant is being considered, this is an aspect that can be overlooked as it is not always seen as being directly relevant to the complication that occurred.

In summary therefore, gastroenterological symptoms are common in the general population at large, and particularly in patients with other medical problems. Whilst many chronic gastroenterological conditions, such as IBS are often considered as trivial they frequently have a significant effect on quality of life and employment. Chronic gastroenterological symptoms can be a consequence of other significant trauma and life events, or by themselves can be an important factor in why Claimants are perceived as being unable to pursue certain careers and activities, even though there is no medical reason why this should be the case if certain, simple allowances are made. Certain environments which people expose themselves to on a regular basis, such as hotels, cruise ships, care homes and hospitals increase the risk of developing acute, infectious gastrointestinal symptoms and although often self limiting, again this can be a component of medicolegal cases which is not considered or opinion sought upon despite the profound effects it can have on Claimants.

by Dr Gerry George Robins Consultant Gastroenterologist FRCP Lond, MD, MBBS

by Dr Gerry George Robins Consultant Gastroenterologist FRCP Lond, MD, MBBS

Page 2

A healthy gastrointestinal system is something that many of us take for granted, and only when it goes wrong do we realise the impact on quality of life, family and employment. Gastrointestinal disease is traditionally something that we in the UK are not very good at talking about, yet in the UK gastrointestinal disease is the third most common cause of death, the leading cause of cancer death and the most common cause of hospital admission (gastrointestinal disease is estimated to be responsible for 1 in 6 admissions to hospital in the UK.

Clearly there are many different types of gastrointestinal disease, and in the field of medicolegal work, first thoughts often turn to abdominal and biliary surgery and its potential complications. However, in the non-surgical field of gastrointestinal disease (Gastroenterology) there is a significant burden of disease, often chronic, which can be overlooked. For example, the Irritable Bowel Syndrome (IBS) is estimated to affect 10 to 25% of the general UK population (with the prevalence in women being between 2 to 4 times greater than in men) and about half of patients with IBS will present to their GP because of symptoms. There is very clear evidence that stress, both acute and chronic, will both precipitate and exacerbate IBS, although the mechanism is not fully understood. There have been numerous trials looking into putative mechanisms, and there is clear data showing that in individuals with IBS who experience stressful or anxiety inducing events, there are changes in the inflammatory profile of both the gut and central nervous system, changes in the endocrine profile of the affected individual (e.g. levels of hormones such as corticotropin and melatonin alter) and also in the bacteria that live within the gut, to name just a few possible mechanisms. Clearly it is entirely plausible that a different mechanism predominates in different individuals, and that there may be multiple mechanisms at work within the same individual. Prognosis in patients with IBS is variable, and compared to healthy controls, patients with IBS are often documented to have extra-abdominal symptoms (e.g. insomnia, sexual dysfunction, urinary symptoms and headache), significantly reduced quality of life, difficulty socialising, reduced participation in sport and travelling and increased absence from work, with a significantly reduced length of working life (with the associated financial implications consequent upon this).

From a medicolegal perspective these facts are important considerations in Claimants who have either developed IBS or had a worsening in their pre-existing IBS symptoms due to a significant life event. Significant life events often precipitate the need for a medicolegal opinion in their own right (e.g. road traffic accident, medical negligence, wrongful dismissal) but the effect on underlying pre-existing, or new, gastroenterological conditions is often overlooked by Claimant’s lawyers when considering all aspects of the case. In other circumstances Claimants who already suffer with IBS may not get the recognition they need from their employer with regards to making appropriate reasonable adjustments within the physical environments of their workplace, and the nature of the work expected to be undertaken. Often patients with IBS need only a relatively small change in work practice to allow them to continue to be productive members of the work team. Simple examples of changes employers could make include allowing the Claimant to come into work an hour or two later (patients with IBS often have worse symptoms first thing in the morning), allowing more working at home (so patients have ready access to their own toilet facilities) and minimising the need for long work-associated periods of travel. The assumption by employers and others that “it’s just IBS” and such patients are exaggerating the impact of their disease on their ability to work, completely underestimates the severity of symptoms that some patients with IBS can have - these symptoms need to be taken seriously.

As IBS is so prevalent another potential mishap is the misinterpretation by a medical practitioner of the development of new symptoms within a patient as heralding the onset of IBS, when in fact the development of new symptoms such as bloating, change in bowel habit, or non-specific abdominal pain is the manifestation of a significant organic disease such as bowel cancer, ovarian cancer or coeliac disease. Occasionally symptoms that should never be interpreted as IBS, are - with potentially significant consequences. Examples of such symptoms that at least initially should not be assumed to be due to IBS include nocturnal symptoms, weight loss, persistence of symptoms despite evacuation of stool, and rectal bleeding. There are very well defined criteria for diagnosing IBS (Rome III criteria) and IBS should always be a “positive” diagnosis and simply not a label given to a patient because their symptoms do not sound like another problem.

In addition to chronic diseases such as IBS, there are acute gastroenterological diseases, which may warrant consideration of a medicolegal opinion. One of the most common scenarios in this group is travel-associated gastroenteritis or traveller’s diarrhoea. In those travelling abroad, especially to countries with a low GDP, it is estimated between 20% and 60% will experience at least one episode of diarrhoea. Whilst usually a self-limiting illness, and rarely life-threatening traveller’s diarrhoea often affects enjoyment of holiday for both the individual affected and other family members and friends in their travelling group. For many families, holidays abroad represent an investment of a significant amount of their disposable income and notwithstanding the unpleasantness of the ongoing symptoms, the need to spend a significant period of time in one’s hotel room unable to participate in activities and/or relaxation is a source of frustration for many people in this circumstance. Often symptoms will continue for a period of time after return to the UK (1 in 20 patients will have symptoms lasting longer than 2 weeks), with Claimants having to miss time off work and reduced other activities for days to weeks afterwards. A causative organism for traveller’s diarrhoea is not identified in up to 70% of cases (as many cases are due to viruses such as norovirus, and many people often do not submit a stool sample), but in those cases where a pathogen is identified, E.Coli is the most common culprit. Destinations considered high risk for traveller’s diarrhoea include South America, Sub-Saharan Africa and South and South East Asia. All inclusive holidays (including cruise ships) and backpacking are also known to increase the risk of developing traveller’s diarrhoea. Typically, episodes of traveller’s diarrhoea start during the first week of travel with most episodes lasting approximately 7 days. A few examples of warning signs for Claimants that hotels or cruise ships may be breaching their duty of care with regards to providing safe food and drink include continually reheating food, serving or handling uncooked food and cooked food together, not serving food at a correct temperature (either not hot enough or not chilled enough), staff handling food not wearing gloves, the presence of animals and insects around eating areas and serving drinks that are watered down or have ice in.

Whilst acute diarrhoeal illnesses are also common in the UK, they do predominate in settings with high levels of contact and potentially compromised hygiene, such as hospitals and nursing homes. Norovirus is the most common cause of outbreaks of infectious diarrhoea in hospitals. This is generally self- limiting and introduced from the community into the healthcare setting through infected patients, visitors and staff (often in the asymptomatic phase of the disease). Clostridium difficile however, whilst a component of the normal gut bacteria of between 3% to 10% of the adult population, is a bacteria that causes a diarrhoeal illness that is one of the most prevalent problems in UK hospitals. The incidence of Clostridium associate diarrhoea increased 4-fold between 1999 and 2004. Prolonged hospitalisation and repeated courses of antibiotics are significant risk factors for developing Clostridium difficile associate diarrhoea. This means it is more likely to be seen in people who are undergoing a complicated recovery from many medical and surgical problems – as by definition this group will very often have a prolonged stay in hospital and often need prolonged and repeated courses of antibiotics. Clostridium difficile associated diarrhoea can evolve into a more severe form of pseudomembranous colits, which in turn can be life threatening and Clostridium difficile infection per se is associated with significant morbidity and
mortality. Again, in medicolegal cases, where the sum total of harm done to the Claimant is being considered, this is an aspect that can be overlooked as it is not always seen as being directly relevant to the complication that occurred.

In summary therefore, gastroenterological symptoms are common in the general population at large, and particularly in patients with other medical problems. Whilst many chronic gastroenterological conditions, such as IBS are often considered as trivial they frequently have a significant effect on quality of life and employment. Chronic gastroenterological symptoms can be a consequence of other significant trauma and life events, or by themselves can be an important factor in why Claimants are perceived as being unable to pursue certain careers and activities, even though there is no medical reason why this should be the case if certain, simple allowances are made. Certain environments which people expose themselves to on a regular basis, such as hotels, cruise ships, care homes and hospitals increase the risk of developing acute, infectious gastrointestinal symptoms and although often self limiting, again this can be a component of medicolegal cases which is not considered or opinion sought upon despite the profound effects it can have on Claimants.

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