liver transplant: now, later or never?
- Really need your opinions on this one. It is pretty interesting.
$5 donation to Healing horses. Can email me privately if you like.
4 month old Baby had a liver transplant.
But for alleged medical malpractice: Could the liver transplant been
prevented or delayed until later in life
was the transplant inevitable at 4 months of age, and therefore, not due to
any medical negligence.
Here's the case:
1. Baby is asian and at 4 months of age was diagnosed with Biliary Atrisia
(BA). BA is more frequently found in asians.
It is a condition where the bile ducts disappear, shrink or were fibrotic and
are unable to carry bile from the liver to the intestines. The symptoms of
BA are jaundice and white stools. The backed up bile ducts eventually cause the
liver to fail.
2. Prior to birth mom had atleast 5 prenatal ultrasounds that showed a
suspicious cyst in Baby's right mid-abdomen. The cyst is not harmful to the baby
prenatally (because the liver is not working like it does outside the womb). Mom
’s OB-GYNs did not know what kind of cyst it was. This is MOM’s first
3. Mom's OB-GYNs knew of the cyst and wanted it checked at birth before the
baby was discharged home. MOM knew the cyst was supposed to be checked at
birth. OB's faxed their records to the hospital and noted it on MOM'S hospital
4. When Baby was born the notes about the cyst were not transferred to Baby's
hospital records (for the pediatricians to review). The nurses knew of the
cyst, but did not know of it's "significance" (if any). Having this cyst is not
necessarily considered to be an emergency situation but it must be evaluated
and monitored to rule out the development of future complications.
5. The OBs never told the pediatricians about the cyst.
6. Mom says she asked two different pediatricians covering for her regular
pediatricians about the cyst before being discharged home and was told
everything was fine. The pediatricians deny this and say she did not ask them about a
cyst. The pediatricians did not review MOM’s prenatal records and did not
speak to the OB-GYNs about any potential problems. The hospital did not transfer
the information about the cyst to Baby’s records. The pediatricians
discharged Baby home without addressing the cyst. No one knew the cyst was a
choledochal cyst – a cyst under the liver near the gall bladder and bile duct.
7. Pediatricians see Baby 7x in her first two months of life for routine
visits and other visits for what MOM believes are feeding and digestive problems.
At 6 weeks old baby appears to have digestive problems, an upper GI is done
by a pediatric gastroenterologist (liver is not viewed in these tests). No
acute liver disease or jaundice is seen. Diagnosis: colic
At 2 months of age MOM switches to new pediatrician because she did not feel
like they were paying attention to her. Baby is seen for some respiratory
problems by the the new pediatrician.
8. At 4 months of age Baby has a distended abdomen (bloated belly), swollen
liver and severe jaundice. she is admitted to the hospital.
Upon admission to the hospital, an ultrasound
revealed that the cyst was a choledochal cyst. Surgery was scheduled to
excise the cyst.
9. During surgery, Dr. Pediatric surgeon (PS) realized that in addition to
the cyst Baby had biliary atresia.
According to Baby's treating pediatric gastroenterologist at that time,
Dr. Williams, the prolonged presence of this choledochal cyst was associated
caused an inflammatory process that obstructed the flow of bile from her
otherwise normal and healthy liver, and over time, ultimately obliterated
her bile ducts and caused a condition that destroyed her liver called
secondary biliary atresia.
The defense says Baby was born with BA which was totally unrelated to the
cyst and that even if the cyst was addressed Baby would still need a liver
The plaintiff says that if the pediatricians addressed the cyst earlier
(shortly after birth), the liver would have been closely monitored and a surgical
correction of the blocked bile flow could have been performed before Baby’s
liver died. If this had been done, Baby
A )would not have needed a liver transplant at age 4 months
B) May not have needed a transplant at all and
C) Would not have developed BA (she was not born with BA).
The defense argues that:
A) . Removal of choledochal cysts are not necessary until symptoms appear
B) It is rare to see BA and choledochal cysts in the same case
C) There is no medical literature which indicates a causal relationship
between choledochal cysts and BA.
D. there is no recognized preventative measures for BA nor is there a known
E. The vast number of patients with BA require a liver transplant.
The evidence/opinions: Plaintiff
Baby's treating liver specialist, as well as the pathologist who examined
her liver, the cyst, and her gall bladder after the transplant, both
confirmed that Baby was not born with biliary atresia and that it developed
Unlike the opinions of the defense experts, these treating physicians base
conclusions upon the fact that Baby had a normal gall bladder (rather than
an atretic gall bladder found with biliary atresia when children are born
with it) and the fact
that Baby did not present with significant abdominal distention or
clinical jaundice for the first two months of her life. Unlike Baby, a
child born without bile ducts would usually suffer rapid onset of abdominal
distention with relentless clinical jaundice soon after birth and be found
with an abnormal or deflated gall bladder.
A liver specialist will testify, on behalf of the plaintiff, that if the
liver had been monitored, blood work would have revealed changes long before Baby
developed visible signs and symptoms and surgery would have been performed
within a couple of weeks of her birth before significant inflammation occurred
within the bile ducts (damaging the liver) and that, more likely than not, Baby
would have avoided the need for a liver transplant. These tests were never
done because the diagnosis was never made until too late.
The evidence/opinions: Defense
1. In order to treat the choledochal cyst, the pediatric surgeon,(PS) planned
surgery to remove the cyst. During surgery Dr. PS discovered that Baby also
had biliary atresia and needed a liver transplant. An ultrasound at birth
would not have detected biliary atresia.
2.A liver specialist will testify, on behalf of defendants, that Biliary
atresia is almost never diagnosed prior to jaundice and other symptoms of biliary
atresia occurring. In this case, Baby did not show symptoms of biliary
atresia until she was four months old.
3. An ultrasound performed after birth would have detected the choledochal
cyst. However, surgical intervention for such a cyst is not done immediately
and is not scheduled until the infant reached approximately three months of
age, as long as the child remains asymptomatic. Surgery is postponed so the
child can grow and better tolerate the effects of surgery and anesthesia. If the
child only has a choledochal cyst, surgery can wait for three months to one
year. This is the case particularly when the child has no symptoms associated
with a known choledochal cyst.
4.After discovering biliary atresia during surgery, Dr. PS performed a Kasai
procedure in which scar tissue is excised from outside the liver and then
tissue from the intestine is connected to the liver to allow bile to flow and
hopefully prevent further bile obstruction within the liver. The Kasai procedure
was unsuccessful and Baby required a liver transplant.
5. The liver transplant was inevitable and earlier intervention would not
have prevented the need for Baby to have a liver transplant at some point.
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