When A Hernia Is Missed on a Normal CT Scan
The following is a hypothetical fact pattern designed to demonstrate a common form of medical error.
- A woman had gastric bypass surgery nine years earlier. She had lost about 100 pounds and had done well since.
- In March she began having attacks of pain in the middle of her belly. The pain came on after eating, lasted an hour or two, then faded. She went to an emergency room three times in five weeks.
- On the third visit a CT scan of her abdomen was done at 10:40 PM. The report said no acute finding. She was given fluids and medicine for nausea, then sent home at two in the morning.
- Two days later her husband could not wake her fully. She was pale and sweating and her heart was racing. She died during surgery that afternoon. The surgeon found several feet of dead small intestine twisted behind her rerouted anatomy.
The short answer
An internal hernia after gastric bypass is a loop of intestine that slips into a space created by the surgery. It then twists and loses its blood supply. It is a surgical emergency.
The failure that repeats in these cases is not a radiologist missing a finding. It is a normal CT scan being treated as the end of the search.
There are two legal questions. The first is whether the care fell below what a reasonably careful provider would have done. The second is whether that failure changed the outcome.
In these cases the fight is usually about what happened after the scan came back. A patient with a gastric bypass and unexplained belly pain needs a surgeon who operates on this anatomy. The rest of this page explains how to tell what happened in your own family member’s case.
If you are not sure this was the diagnosis, start with our overview of serious causes of severe abdominal pain.
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Article written by Gregory Unatin, Esq. Greg is a managing partner in the law firm of Lupetin & Unatin, a medical malpractice law firm located in Pittsburgh and serving Western Pennsylvania.
Our practice is limited to high-value catastrophic cases because that is where we can do the most for our clients and for patient safety.
What an internal hernia after gastric bypass is
A Roux en Y gastric bypass reroutes the intestine. The surgeon divides the small bowel and brings one end up to the small stomach pouch. That rerouting leaves gaps inside the abdomen, in places where nothing used to be.
A loop of small bowel can slide into one of those gaps. At first it may slide back out on its own. That is why the pain often comes and goes for weeks before anything terrible happens.
Then one time it does not slide back. The trapped loop fills and swells. The swelling makes the opening it came through even tighter. Now both ends are pinched off, which surgeons call a closed loop.
The vessels feeding that loop are pinched in the same twist. Blood cannot get out, then it cannot get in. The bowel wall swells, then it dies. None of this reverses on its own, because the swelling that traps the loop is caused by the trapping.
Why an internal hernia after gastric bypass gets missed
This diagnosis hides better than almost anything else in the abdomen.
The pain comes and goes. A patient can have several episodes over weeks or months. In between she feels fine and looks fine. If the loop has slid back out by the time she reaches the emergency room, the examination of her belly can be completely normal.
Her vital signs are often normal too. So is her white blood cell count. Nothing on the outside of the patient tells you that a loop of bowel keeps falling into a hole.
The pain also has the wrong shape. Pain that starts after eating and eases up sounds like a stomach problem, not a surgical one. So an internal hernia after gastric bypass gets called reflux, an ulcer, gallbladder disease, dumping syndrome, or anxiety.
That mistake is understandable, and we say so plainly. All of those conditions are common after bypass surgery. Dumping syndrome, where food moves too fast into the intestine, is an expected side effect of the operation. Most bypass patients who come in with belly pain do not have an internal hernia.
The test that should have been done, and what it cannot do
A CT scan of the abdomen is the imaging study used here. It is the right first test. It is not a test that can clear the patient.
CT can suggest an internal hernia. A radiologist who knows this anatomy looks for the mesentery, the fan of tissue that carries blood to the bowel, appearing swirled or twisted. There are several other signs of the same kind. When they are present, the diagnosis is often made.
The problem is what happens when they are absent. A normal CT scan does not rule out an internal hernia after gastric bypass. Patients have had normal scans and dead bowel on the same day. While CT scan is the diagnostic test of choice, a normal scan does not definitively rule out an internal hernia if clinical suspicion remains high.
When clinical suspicion for an abdomen that requires surgery remains high despite a non-diagnostic CT scan, diagnostic laparoscopy is the definitive diagnostic and therapeutic next step. Surgeons accept that they will sometimes look and find nothing, because the alternative is sending home a patient whose bowel is dying.
The clock
Time is the whole case here. Once the loop closes off the timeline for action can vary but is often only hours before permanent harm results. The trapped bowel swells and its blood supply strangles. Living bowel becomes dead bowel, and dead bowel cannot be saved. It can only be cut out.
The treatment is surgery. A surgeon untwists the loop, checks what is still alive, removes what is not, and closes the gap so it cannot happen again. How much bowel comes out depends almost entirely on how long the loop was closed.
There is usually a second clock in these records, and it is longer. The episodes that came and went for weeks are the warning shots. Those visits are almost always documented somewhere, which means the chance to catch this was on paper before the day it became fatal.
Who is at highest risk
- Anyone who has had a Roux en Y gastric bypass. There is no point at which the risk goes away.
- Time since surgery does not protect the patient. These happen years later, sometimes more than ten years later.
- Significant weight loss raises the risk. As fat inside the abdomen disappears, the spaces created by the surgery get roomier.
- Pregnancy after a bypass raises the risk, because a growing uterus shifts the bowel.
- A history of earlier episodes of the same pain. A loop that has fallen into a gap before can fall into it again.
This article has a fuller discussion of who is at risk for serious abdominal emergencies generally.
What to look for in the records
These are things you can look for yourself, or ask us to look for.
- The operative report from the original bypass. It establishes the anatomy and whether the surgeon closed the gaps.
- Whether the bypass is mentioned anywhere on this visit. Check the triage note and the history section of the physician note.
- Every earlier visit for similar pain. Look at triage complaints and discharge instructions, not just the diagnosis codes.
- The exact words of the CT report. Note whether the rerouted anatomy or the mesentery is discussed at all.
- What the CT was ordered for. The order tells you what the radiologist was asked to look for.
- Whether a surgeon was called, and at what time. If no consult note exists, that absence is itself a finding.
- Whether a bariatric surgeon or a general surgeon was involved, and whether anyone reached out to the original surgeon.
- The nursing flow sheet, especially a heart rate that climbs across the visit.
- Lab results with their times, including lactate if it was drawn. Note whether anything abnormal was rechecked.
- Nursing notes on vomiting, distension, and whether gas or stool was passing.
- The operative report and the pathology report. They describe how much bowel was dead and what it looked like.
Note: Several of these being present do not prove a case, and one missing item does not rule one out.
What none of this proves
We will not pretend this diagnosis is easy, because families reading this page were told it was hard and sometimes that was true.
Here is the defense case, stated fairly. The symptoms of an internal hernia after gastric bypass look like the symptoms of several harmless things. Imaging for this condition is genuinely unreliable, and radiologists disagree about the same scan. Few general emergency physicians have real experience with this anatomy. And surgeons who do explore these patients often find no hernia at all, which is the defense’s argument that watchful waiting was reasonable.
All of that can be true and the case can still be a good one. The two questions stay the same. Did the care fall below the standard, and did the failure change what happened.
Our argument is not that anyone should have known the diagnosis from across the room. It is narrower and harder to answer. This patient had findings already in this chart that called for the next step, and the next step did not happen.Â
How people die from this, and what happens to those who survive
Death from an internal hernia after gastric bypass usually comes one of three ways.
The most common is septic shock. Dead bowel leaks bacteria into the bloodstream. Blood pressure falls, organs shut down, and by the time the patient reaches an operating room the shock cannot be reversed.
The second is perforation. Dead bowel splits open and spills its contents into the abdomen. That causes an overwhelming infection of the abdominal cavity.
The third is the extent of the loss itself. When a long segment infarcts, meaning it dies from lack of blood, some patients cannot survive it even with perfect surgery.
Among those who live, the catastrophic injury is losing too much bowel. Surgeons remove what has died. Here that can be a very long stretch, because one twist can catch a large part of the small intestine.
If enough bowel is gone, the patient has short bowel syndrome. The remaining intestine cannot absorb enough nutrition from food. That can mean feeding through a vein, sometimes for life, along with repeat operations and liver damage from the feeding itself. Â However, short bowel syndrome is a very uncommon outcome.
How we prove a case like this
- The original bariatric operative report. It tells our experts what anatomy existed inside this patient and where the spaces were.
- Every prior visit for the same pain. A pattern of episodes is the evidence that this was not a first presentation of vague pain.
- The CT images themselves, not just the report. We have them read again by a radiologist who reads bypass anatomy, which sometimes shows that the findings were there.
- The timeline of the surgical consultation. When a surgeon was called, and whether anyone with bariatric experience was involved, is often the center of the case.
- The operative report and pathology. The description of the bowel tells us how long it had been dying, which is how we connect the delay to the outcome.
Cases like this need a bariatric surgeon, an emergency physician, and a radiologist. A general surgeon is often needed as well.
Pennsylvania also requires a licensed professional to certify that the care fell below the standard before a case can move forward. Our hub page walks through how we investigate these cases from the first call to filing.
This condition has close cousins. If there was no prior bypass, see our pages on a twisted bowel and a strangulated hernia.
Frequently Asked Questions
Because a normal CT scan does not rule out an internal hernia after gastric bypass, and that has been known for a long time. The claim is usually not that the radiologist should have seen it. The claim is that the treating providers relied on a test that cannot answer the question. In a bypass patient with unexplained pain, the answer comes from a surgeon willing to look. A normal scan should have narrowed the search, not ended it.
Yes. The spaces created by the surgery do not close on their own with time. Internal hernias happen many years out. The years of doing well are sometimes used as a reason the diagnosis was not considered. A new pattern of pain in a bypass patient deserves more attention, not less.
In Pennsylvania, a medical malpractice lawsuit must be filed in a proper court within two years of the date of death or in the absence of death, the date when the patient knew or should have known they suffered an injury which may have been related to health care.
The start of the two-year period depends on the facts. Some are shorter than people expect. Call before you assume it is too late.
No. We review these cases at no cost, and we do not charge for the investigation. If we take the case, our fee comes out of a recovery. If there is no recovery, nothing is owed.
No. We obtain records with your authorization, and we know which ones matter here. Bring whatever you already have. What helps most is not paperwork but your memory of the earlier visits.
What to do now
Gather what you have at home. That means discharge instructions from every visit, the death certificate if there is one, and the name of the original surgeon. Then write down the episodes while you remember them. Note dates, what she ate, how long the pain lasted, and what she was told. That timeline is evidence, and families are the only ones who can build it. Then contact our office.