Bowel Ischaemia (Mesenteric Ischaemia) Misdiagnosis and Delayed Diagnosis Claims

What bowel ischaemia/mesenteric ischaemia means in practice

To understand this condition simply, think of it like a heart attack of the gut. Just as a blocked vessel in the heart stops blood reaching the heart muscle, a blocked vessel in the abdomen stops blood reaching the intestines.

The medical term comes from the mesentery, which is the system of blood vessels that attaches the bowel to the body wall and supplies it with blood. When this flow is interrupted, the bowel begins to starve of oxygen.

The difference between acute and chronic mesenteric ischaemia

Doctors generally divide this condition into two categories, depending on how quickly it happens:

• Acute Mesenteric Ischaemia (AMI): This is a sudden and severe blockage. It is a medical emergency. It is often caused by a blood clot (embolus) travelling from the heart or a clot forming directly in the artery (thrombus). The symptoms come on very quickly.
• Chronic Mesenteric Ischaemia (CMI): This is a slower, long-term condition. It is caused by a gradual narrowing of the arteries supplying the bowel, similar to how arteries narrow in heart disease (atherosclerosis). Patients often suffer pain for months before a complete blockage occurs. This is sometimes called "intestinal angina."

Why timing is important

In cases of bowel ischaemia, time is tissue. The bowel is incredibly sensitive to a lack of oxygen.

• Within hours: The cells lining the bowel begin to die.
• Without rapid intervention: The bowel wall can break down, allowing bacteria to leak into the bloodstream (sepsis).
• The window for saving the bowel: The best outcomes occur when blood flow is restored before permanent necrosis sets in. If diagnosis is delayed beyond this window, the only option is often to surgically remove the dead sections of the bowel.

Who may be at higher risk

While this can happen to anyone, clinicians should be on high alert if a patient has certain risk factors. A failure to consider these factors when a patient presents with abdominal pain may be relevant to a negligence claim.

Common risk factors include:

• Atrial Fibrillation (AFib): An irregular heartbeat is a leading cause of clots that travel to the bowel.
• Vascular Disease: A history of hardening arteries, high cholesterol, or previous stroke/heart attack.
• History of Smoking: Long-term smoking damages blood vessels.
• Previous Clots: A history of Deep Vein Thrombosis (DVT) or Pulmonary Embolism (PE).
• Heart Failure: Reduced blood pumping can lower blood flow to the gut.

How mesenteric ischaemia is commonly missed

One of the greatest challenges in treating bowel ischaemia is that it is a "great mimic." Its symptoms look very similar to many other, less serious abdominal conditions.

However, medical professionals are trained to rule out life-threatening conditions first. A misdiagnosis often occurs when a doctor assumes the patient has a common bug without considering the possibility of ischaemia, despite risk factors being present.

Conditions it often resembles include:

• Gastroenteritis: Often dismissed as a "tummy bug" or food poisoning.
• Pancreatitis: Inflammation of the pancreas causing central tummy pain.
• Appendicitis: Infection of the appendix (though ischaemia pain is often more widespread).
• Bowel Obstruction: A physical blockage in the gut.
• Kidney Stones: Severe pain that can radiate through the abdomen/back.
• Peptic Ulcer Disease: Pain from stomach ulcers.

System factors that contribute to delay

In the busy environment of an Irish hospital, system failures can contribute to a missed diagnosis. This does not always excuse the error, but it helps explain how it happens.

• Triage Pressure: Patients may be categorised as "non-urgent" because their vital signs (blood pressure/heart rate) might appear normal in the very early stages.
• Non-Specific Symptoms: Because the symptoms are vague, junior doctors may discharge a patient with painkillers, advising them to see their GP, missing the window for treatment.
• Imaging Waits: Delays in getting a CT scan, or waiting for a senior radiologist to review the scan out-of-hours.
• Handover Gaps: Information being lost when care is transferred from the night team to the day team.

Symptoms and red flag features clinicians look for

Competent medical care involves looking for specific "red flags" that distinguish ischaemia from a simple stomach ache.

Acute presentation red flags

• Sudden onset: Pain that starts instantly and reaches peak intensity quickly.
• Forceful bowel emptying: The body tries to "empty" the gut, leading to sudden vomiting or diarrhoea (sometimes bloody).
• History of heart issues: As mentioned, a patient with AFib complaining of tummy pain is a major red flag.

Chronic presentation red flags

• Post-prandial pain: This refers to pain that occurs 15 to 30 minutes after eating. This is because digestion requires more blood, which the narrowed arteries cannot supply.
• Food fear and weight loss: Patients stop eating because they are afraid of the pain, leading to unintentional weight loss.
• Recurring episodes: A history of "stomach aches" that doctors haven't been able to explain.

"Pain out of proportion" to physical exam

This is the single most critical sign of mesenteric ischaemia. In medical terms, this describes a situation where the patient is in agony, crying out or requiring strong morphine, but when the doctor presses on their stomach, it feels soft and relatively non-tender.

In conditions like appendicitis, the stomach usually feels rigid or hard. In early bowel ischaemia, the stomach feels soft because the problem is inside the vessels, not the abdominal wall. If a doctor sees a patient in extreme pain with a soft tummy, they must suspect ischaemia until proven otherwise.

How the condition is investigated and diagnosed

If a doctor suspects bowel ischaemia, there are specific protocols they should follow. Failing to order the right test at the right time is a common basis for clinical negligence claims.

History and examination protocols

The doctor should take a thorough history, specifically asking about heart rhythm (AFib), previous clots, and pain patterns regarding eating. A physical exam involves listening to the abdomen with a stethoscope (bowel sounds may be silent in late stages) and checking for the "pain out of proportion" sign.

Blood tests

Doctors will take blood samples to look for signs of infection or stress in the body.

• Lactate (Lactic Acid): High levels of lactate can indicate that tissue is dying.
• White Cell Count: High levels indicate infection/inflammation.

However, it is vital to note: A patient can have normal blood results in the early stages of ischaemia. A doctor should not rule out the condition solely because blood tests are normal. Relying too heavily on "reassuring" bloods while ignoring the patient's severe pain is a common error.

CT angiography

The "Gold Standard" test for diagnosing mesenteric ischaemia is a CT angiogram (CTA).

This is different from a standard CT scan. A standard CT might show the bowel looks okay, but miss the blockage in the vessel. A CT angiogram, on the other hand, involves injecting a contrast dye into the veins. This dye highlights the blood vessels, allowing the radiologist to see if an artery is blocked or narrowed. If ischaemia is suspected, this scan should happen immediately. Waiting until the next morning can be fatal for the bowel tissue.

What can happen when diagnosis is delayed

When bowel ischaemia is caught early, surgeons can sometimes remove the clot or place a stent to restore blood flow, saving the bowel. When it is missed or delayed, the consequences are devastating.

Emergency surgery and bowel resection

If the tissue has died (necrosis), it cannot be saved. The surgeon must remove the dead section of the intestine. This is called a bowel resection. The more time that passes, the more bowel tissue must be removed.

Longer-term consequences

• Stoma formation: Often, the surgeon cannot join the healthy ends of the bowel back together immediately. The patient may wake up with a stoma (colostomy or ileostomy), where waste is collected in a bag attached to the stomach wall. This may be temporary or permanent.
• Short Bowel Syndrome: If a large amount of small intestine is removed, the body cannot absorb enough nutrients from food.
• Nutritional Support (TPN): Patients with Short Bowel Syndrome may need to be fed intravenously (Total Parenteral Nutrition) for the rest of their lives. This requires complex home care and carries risks of liver damage and infection.

Impact on day-to-day life

The aftermath of a missed diagnosis extends far beyond the hospital stay.

• Fatigue and weakness from major surgery and nutritional deficits.
• Inability to return to work due to care needs.
• Dietary limitations and strict management of fluid intake.
• Psychological impact of adjusting to life with a stoma or chronic illness.

When a missed diagnosis may raise concerns about clinical negligence

Not every bad medical outcome is due to negligence. Medicine is complex, and sometimes conditions are masked. However, if the care provided fell below an acceptable standard, you may have a case.

The standard of care and reasonable clinical decision-making

In Irish law, the test for medical negligence focuses on whether the doctor followed a practice accepted as proper by a responsible body of medical opinion (often referred to as the Dunne principles).

We ask: "Would a competent doctor, acting with ordinary care, have missed these signs?"

If a patient presented with classic "pain out of proportion" and a history of AFib, but was sent home with antacids without a CT scan, this may be considered a breach of duty.

Causation: linking delay to avoidable harm

It is not enough to prove the doctor made a mistake; we must prove the mistake caused the injury. This is known as causation.

• The "But For" Test: We must show that, but for the delay, the outcome would have been better.
• Example: If the diagnosis had been made 6 hours earlier, could 50cm of bowel have been saved? Would the patient have avoided a permanent stoma?
• If the bowel was already dead when the patient first arrived at the hospital, the delay might not have changed the outcome. These are complex medical arguments that require expert analysis.

The role of independent expert evidence

At Michael Boylan LLP, we do not guess. We engage leading independent medical experts from outside Ireland (often from the UK) to review the files. We will instruct:

• An Emergency Medicine Consultant to review the initial triage and assessment.
• A Vascular or General Surgeon to opine on what treatment should have happened and what the outcome would have been.
• A Radiologist to review if scans were reported correctly.

Evidence that is often important in these cases

To build a strong case, we need to reconstruct the timeline of events minute-by-minute.

Documents we examine include:

• GP and Out-of-Hours Records: Did the patient visit a doctor before going to the hospital? What was recorded?
• Emergency Department (ED) Notes: Triage times are crucial. How long did the patient wait to see a doctor? When was the pain relief given?
• Imaging and Radiology Reports: We look at the time the scan was ordered, the time it was performed, and the time the report was typed. We also check for "amended reports" (where a diagnosis was added later).
• Medication Charts: High doses of morphine without effect is a key piece of evidence regarding pain levels.
• Escalation Notes: Did a junior doctor try to call a consultant? Was there a delay in the senior doctor arriving?

Legal process for bowel ischaemia claims in Ireland

The limitation period and “date of knowledge”

Generally, the Statute of Limitations allows two years to bring a claim.

• This clock usually starts ticking from the date the injury occurred.
• However, in misdiagnosis cases, the "Date of Knowledge" is important. The clock may only start when you found out (or should have known) that the injury was due to negligence.
• Exception: For children, the two-year limit does not begin until they turn 18.

Bowel ischaemia claims are not assessed by the Injuries Resolution Board

Unlike car accidents or slips and falls, medical negligence claims are not assessed by the Injuries Resolution Board (formerly PIAB).

The Injuries Resolution Board explicitly excludes medical negligence from its remit because these cases are too complex. This means you cannot simply fill out a form to get an assessment; you generally need to issue court proceedings to resolve the matter. This makes having a specialist solicitor essential.

After instructing a solicitor, the following steps usually apply:

1. Investigation: We gather records and get expert reports. This is the longest phase.
2. Letter of Claim: If the experts support the case, we write to the HSE or hospital detailing the allegations.
3. Proceedings: We issue a summons.
4. Settlement or Trial: The vast majority of valid claims settle before reaching a courtroom.

Complaints, reviews and getting answers

Many of our clients simply want an apology or an explanation of what went wrong.

The HSE “Your Service Your Say” route

You have the right to make a formal complaint through the HSE’s "Your Service Your Say" process. This triggers an internal review.

• Pros: It can provide a timeline and sometimes an apology.
• Cons: It is an internal investigation by the hospital (marking their own homework). It does not result in compensation for lost earnings or care costs.

Complaints vs legal advice

You can run a complaint and a legal investigation at the same time. However, be aware that the hospital’s legal team will review any responses to your complaint once litigation is threatened. We can advise you on how to handle the complaints process alongside a legal inquiry.

How Michael Boylan LLP can assist with mesenteric ischaemia misdiagnosis concerns

We are recognised as one of Ireland’s leading medical negligence law firms. We do not dabble in other areas of law; medical litigation is what we do.

Our focus on case preparation

These cases are scientifically complex. A general solicitor may miss the subtle vascular arguments required to win. We have an in-house team that includes medical professionals, ensuring we understand the clinical reality of your case from day one. We approach every case with empathy, knowing that you have likely been through a traumatic ordeal.

What information to have ready

If you would like to speak with us, it is helpful (but not strictly necessary) to have the following:

• Dates of admission to the hospital.
• Names of the hospitals and doctors involved.
• A rough timeline of when symptoms started and when the diagnosis was finally made.
• Details of the outcome (e.g., length of bowel removed, current care needs).

Frequently Asked Questions

What is the difference between misdiagnosis and delayed diagnosis in mesenteric ischaemia?

Misdiagnosis is when the doctor diagnoses the wrong condition (e.g., saying it is gastritis) and discharges the patient. Delayed diagnosis is when the correct diagnosis is eventually made, but it took too long (e.g., waiting 24 hours for a scan), causing the patient to suffer more injury than necessary.

Can mesenteric ischaemia be missed on a CT scan?

Yes. If the CT scan is done without contrast dye (a non-contrast CT) or if the timing of the contrast is wrong, the blood vessels may not show up clearly. A specific CT Angiogram is required to properly visualise the arteries feeding the bowel.

What records should I request (GP, hospital, radiology)?

Ideally, you need the full set of medical records. This includes handwritten clinical notes, nursing notes, medication charts, operation notes, discharge summaries, and crucially, the radiology discs (the actual images) and reports.

Are medical negligence cases assessed by the Injuries Resolution Board?

No. The Injuries Resolution Board (formerly PIAB) does not deal with medical negligence cases. These claims are complex and must be managed through the courts, typically the High Court given the serious nature of the injuries.

How are time limits worked out if I only discovered the issue later?

The two-year limit generally starts from your "date of knowledge." This is the date you first realised,or a reasonable person would have realised,that the injury was significant, attributable to the medical treatment (or lack thereof), and justified a claim. Establishing this date can be legally technical, so urgent advice is recommended.

Do you have questions about your care?

If you or a loved one has suffered due to a missed or delayed diagnosis of bowel ischaemia, you need answers. We provide a confidential, professional environment to discuss what happened.

Contact Michael Boylan LLP today to arrange an initial consultation.

*In contentious business, a solicitor may not calculate fees or other charges as a percentage or proportion of any award or settlement.