When Trapped Bowel Dies
The following is a hypothetical situation designed to demonstrate a common form of medical error. It is not a real case, and no physician has reviewed it or offered an opinion about it.
Two visits, 22 hours apart
The following is a hypothetical situation designed to demonstrate a common form of medical error. It is not a real case, and no physician has reviewed it or offered an opinion about it.
A man of 71 had a bulge in his groin for 10 years. It had always flattened out when he lay down, and he had been told to leave it alone. On a Sunday at 5:20 in the evening he came to an emergency department with 9 hours of cramping pain and 4 episodes of vomiting. His pulse was 108, and he had not passed gas since the night before. The triage note said abdominal pain and vomiting. The physician note said the abdomen was soft and did not mention the hernia. He was given fluids and medication for nausea, told he had a stomach virus, and discharged at 9:05 that night. He came back by ambulance 22 hours later with a pulse of 134 and a firm, tender bulge that would not go down. He was in the operating room by 11:30 that night. Sixteen inches of dead intestine were removed, and he woke up with an ostomy.
The short answer
A strangulated hernia is a hernia with intestine trapped in it, where the trapped piece has lost its blood supply. Trapped bowel that is not freed dies.
Most hernias are not emergencies. Most people who have one for years never end up in surgery. What makes this an emergency is a change. The bulge that always went back in no longer goes back in, and it starts to hurt.
A failure that repeats in these cases is not a hard diagnosis missed by a careful examiner. It is a hernia that never gets examined at all.
There are two legal questions. Did the care fall below what a careful doctor, nurse, or hospital would have done? And would an operation have changed the outcome?
The rest of this page explains how to tell what happened in your own case. Our guide to severe abdominal pain emergencies covers the other conditions that go wrong this way.
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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 a strangulated hernia actually is
A hernia is a gap in the wall of the abdomen. Fat, or a loop of intestine, pushes through and makes a bulge under the skin. Usually, the contents slide back in when the person lies down. Doctors call that reducible, meaning it can be pushed back.
Sometimes the contents get stuck. Doctors call that incarcerated, meaning trapped. An incarcerated hernia is not the same thing as a strangulated one, and this distinction matters. Plenty of hernias get stuck without the bowel dying.
In the worse-case scenario, strangulation is the next step. The gap squeezes the loop, and the loop swells because it is squeezed. The swelling makes the squeeze tighter, and the small vessels in the wall of the bowel get pinched shut. The loop is no longer just stuck. It is starving for oxygenated blood to support the bowel tissue, and starved bowel starts to die.
This is why waiting does not help the way it helps some other blockages. The swelling that traps the loop is caused by the trapping. Â Bu early surgical intervention can reverse ischemia before irreversible bowel death occurs, preventing bowel resection
Usually, the trapped loop also blocks the intestine, which is why pain comes in waves and vomiting starts. That is not universal. When only part of the wall of the bowel is caught, the intestine can still empty. A patient can then have a dying segment without much vomiting.
Why a strangulated hernia gets missed
Start with the part that is nobody’s fault. Longstanding hernias are common, and the overwhelming majority of them do not strangulate. A patient who has been told for years that the bulge is nothing has usually been told the truth.
The mistake in these cases is a specific one. It is treating a hernia the patient has had for years as a hernia that has not changed. The entire emergency lives in the change, and the change is a question somebody has to ask.
The examination is where it goes wrong. Sometimes the hernia is never examined, because the complaint was recorded as belly pain rather than a groin problem. Sometimes the note says the abdomen is soft, which can be accurate and still say nothing about the groin.
Then the symptoms point somewhere else. Cramping pain and vomiting in an older patient sounds like a stomach virus, or constipation. Fluids and medication for nausea help a stomach virus. They also make a patient with a strangulated hernia feel better for an hour or two.
That mistake is understandable, and we say so plainly. Gastroenteritis, meaning a stomach virus, is far more common than a strangulated hernia. Examining the groin of a patient with obesity is genuinely harder. And a patient who has heard for a decade that the bulge is nothing may not think to mention it.
What is harder to defend is a chart with no answer in it. If nobody looked, nobody can say whether the hernia had changed.
The examination that should have been done, and what a scan can add
The hernia examination. This is the center of these cases. It means looking at and feeling the bulge, in a patient who is lying down, and recording three things. What the bulge looks and feels like. Whether it goes back in. Whether touching it hurts. A hernia that is newly firm, newly tender, and will not go back in is a surgical problem, not a discharge.
The history is part of that examination. When did the bulge stop going back in. When did it start hurting. When did the patient last pass gas or stool. Those answers are usually there for the asking.
The attempt to push it back in. Whether a reduction should be tried at all is a judgment for someone qualified to make it, and it depends on the findings. Forcing one can do harm, including pushing injured bowel back inside where nobody can see it. What is not a plan is an attempt that fails, followed by discharge.
The CT scan. A CT scan of the abdomen and pelvis can show what is inside the hernia and whether the intestine above it is blocked. It can also show signs that the trapped bowel is in trouble. What it cannot reliably do is tell you the bowel is still healthy. Those findings can appear late, so a scan without signs of potentially harmful bowel changes does not end the clinical analysis. A scan is also not a substitute for a hernia examination.
Blood work. A lactate level rises when tissue is not getting enough oxygen, and a high value is meaningful. A normal lactate level does not completely rule out early strangulation, because lactate tends to rise late. The same goes for a normal white blood cell count.
The clock
Once a loop is strangulated, the injury runs on its own schedule.
Pressure inside the trapped loop keeps rising. The vessels in its wall get squeezed shut. Without blood the wall begins to die, and dying bowel leaks. Intestinal contents spill into the abdomen and cause peritonitis, meaning infection of the lining of the belly. Blood pressure falls and organs begin to fail.
Nobody can pin the survival of a trapped loop to a specific number of hours, and it varies from patient to patient. What is not in dispute is the direction. Earlier surgery is more likely to find living bowel, and later surgery finds dead bowel.
The treatment is an operation. A surgeon opens the hernia, frees the trapped loop, looks at it, and removes what cannot be saved. Then the gap in the abdominal wall gets closed. How much intestine comes out depends almost entirely on when the operation happens.
In this case, the hernia should have been examined and a surgeon called on the first visit. An operation that night would likely have found living bowel.
Who is at highest risk
- Anyone with a known hernia. The people this happens to usually knew they had one.
- Prior abdominal surgery, because operations leave both scar tissue and weak spots in the wall.
- Obesity, which makes the examination harder and can hide a small hernia entirely.
- Older age, because tenderness and fever are often muted and the trend in the vital signs is the only signal.
- Recent straining or heavy lifting, which is often what pushed the loop through in the first place.
Our article on severe abdominal pain covers the broader risk factors across these emergencies.
What to look for in the records
These are things you can check, or ask a lawyer to check.
- The physician note from the visit, and whether the hernia appears in it at all.
- Whether an attempt to push the hernia back in is documented, and what happened when it was tried.
- Prior records from a primary care office or a previous visit, showing the hernia had always gone back down.
- The complete vital sign record for the visit, read as a trend rather than one number at a time.
- The nursing notes, for vomiting, passing gas or stool, and any description of the bulge.
- Whether a CT was ordered, what the order said the question was, and what the report says about the hernia contents.
- Whether a surgeon was consulted, at what time the request was placed, and when it was answered.
The central question: was there enough in this chart to require a surgeon that day?
Most hernias never strangulate. A doctor who sends every patient with a longstanding bulge to a surgeon will send many people who did not need to go. A strangulated hernia can also look like a stomach virus early on. A defense expert will say the presentation was nonspecific and the examination difficult, and that hindsight makes a hard call look obvious. Sometimes that is right.
The two central questions remain. Did the care fall below what a careful doctor, nurse, or hospital would have done in the same situation? And would an operation at the point the hernia changed have changed the outcome?
The argument here is not that this diagnosis is easy. It is narrower. It is that this patient came in with a hernia he had carried for years, new pain, and vomiting. The chart holds no record that anyone looked at the hernia or asked whether it had changed. The medical evidence must then show that looking would have led to the operating room in time to matter.
How people die from this, and what happens to those who survive
Most patients with a strangulated hernia who reach an operating room in time recover and go home.
When it goes the other way, it usually goes one of three ways. The most common is a leak from the dead loop, causing peritonitis and then septic shock, where blood pressure stops responding and organs fail. The second is death in the days after an operation that came too late, in a patient too frail to recover from it. The third is aspiration, meaning vomit going into the lungs.
Among those who survive, the injuries that permanently change a life are these, most common first.
- Loss of a length of intestine, with an ostomy, meaning the bowel empties through an opening in the skin into a bag. Some are reversed later and some are permanent.
- An open abdomen, where the belly cannot be closed at the end of the operation and is left open under a dressing for days. Patients who go through this often need a major reconstruction later.
- Short bowel syndrome, meaning so little intestine is left that the person cannot absorb enough food and lives on nutrition through a vein. This one is uncommon after a hernia, because usually one loop is involved rather than many feet of bowel. It is also the hardest to live with.
How we prove a case like this
A handful of records decide this condition.
Whether a hernia examination was documented at all, and what it said, is usually the first thing we look for and often the whole case. Prior records establishing that the hernia had always been reducible are what turn the visit into a change rather than a baseline. The time to surgical consultation shows where the hours went, and whether anyone treated this as urgent. The operative report describes the state of the bowel, which is how we work backward to what an earlier operation would have found.
These cases usually need emergency medicine, general surgery, and radiology.
Pennsylvania also requires a licensed professional to certify that the care fell below the accepted standard before a case can move forward. Our hub article walks through the full investigation process.
Two other conditions on our site injure the bowel in the same way. One is a twisted intestine, which strangles a loop by a different mechanism. The other is a blockage from scar tissue, where the trapped loop sits inside the abdomen instead of inside a hernia.
Frequently Asked Questions
Because the hernia was not the emergency. The change was. For 10 years the bulge went back in, which meant nothing was being squeezed hard enough to lose its blood supply. When it stopped going back in and started to hurt, it became a different problem with a different clock. The years of being told it was nothing are not a defense to failing to check whether this time was different.
It matters less than people assume. Patients report the symptom that hurts most, and pain and vomiting outrank a bulge they have lived with for years. The examination exists to find what the patient did not think to say. In a patient with belly pain, vomiting, and a known hernia, checking the hernia is part of the job.
No. The records that matter here are often the ones that are hardest to get, including nursing notes, vital sign flowsheets, and consultation times. We request the complete chart ourselves. If you already have paperwork, bring it, but do not wait on it.
No. An initial conversation is free, and so is our review of the case. We work on a contingency basis, which means a fee only if we recover money for you.
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 practical point is that these cases turn on one examination, and on what the people in the room remember. Waiting costs you something even when no deadline is close.
What to do now
Gather what you have: discharge paperwork, any operative report, the death certificate if there is one, and the hospital name and dates. Then write down what you remember about the hernia, while it is fresh. How long he had it. Whether it always went back in. When it stopped going back in. Who he told, and what they said. Families are often the only source for how that bulge behaved for years, and that is evidence. Then call us.