Case Archive
Pediatric Radiology, Pediatric Emergency Medicine
Ref. # 44197

A five year old Pennsylvania girl was taken to the ER with symptoms of abdominal pain, vomiting and diarrhea, all of which had developed within the previous few hours. On physical examination she was afebrile but mildly tachycardic. She appeared in acute pain and had grunting respirations. Abdominal examination demonstrated mild left upper quadrant tenderness but no masses or peritoneal signs. In reviewing chest radiographs the ER physician noted "some obscuring of the left hemidiaphragm" but he was not convinced there was an infiltrate. The child's pain was resolved and she was discharged to home with a diagnosis of gastroenteritis. The ER physician informed the parents the radiographic interpretation was abnormal and follow-up would take place later that morning. A radiologist at the hospital reviewed the radiograph and noted "elevation of the left hemithorax with accentuation of the interstitial markings within the left base indicative of atelectasis involving the left lower lobe." He called these findings to the ER, where another physician phoned the parents and prescribed the antibiotic Pediazole. Late afternoon at home, the child vomited, became short of breath then suffered a seizure and became unresponsive. Paramedics took her to the hospital, where resuscitative efforts were unsuccessful. A radiograph at that time revealed herniation of intra-abdominal contents into the left hemithorax, which was confirmed at autopsy. The cause of death was listed as congenital defect of the left hemidiaphragm with herniation of abdominal viscera into the left chest. At the request of the coroner, an independent radiologist reviewed the initial radiographs and noted a defect in the diaphragm and dilated bowel with air fluid levels, possibly stomach or other bowel displaced upward into the lower hemithorax with indistinct margin. After reviewing same, a medQuest pediatric radiologist reported on the lateral view of the chest that there was a loop of bowel above the anterior aspect of the diaphragm, indicating the presence of a hernia. The radiologist negligently failed to comment on this abnormality and recommend further testing. The delay in diagnosis resulted in the massive dilation of the bowel loops and the child's death. A medQuest pediatric emergency medicine specialist independently concurred with this opinion and added with timely surgical evaluation and intervention the child would have lived.

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