DELAYED DIAGNOSIS OF INTESTINAL MALROTATION IN A NEWBORN INFANT

Learning objectives: To illustrate a delayed diagnosis of intestinal malrotation in a newborn infant due to cognitive biases.  

Case information: A 12-day-old infant presented with vomiting and bloody stool.  On 6th day old, he started to have vomiting followed by irritability and diarrhea. He was switched to different feeding formula, which did not help relieved the symptoms.  Six days later, he started to have mucus bloody stools and periods of inconsolable cry. An abdominal radiograph showed right lower gas paucity suggestive of intussusception. The infant was then transferred to a tertiary care hospital for surgical consultation with the concern of intussusception. A contrast enema showed equivocal: the contrast media failed to progress at the hepatic flexure that raised the suspicion for intussusception, although, it was reported to be atypical for intussusception. An ultrasonogram revealed no intussusception. During the course of his hospitalization, his abdomen was benign but he continued to have the episodic cry.  A small bowel follow thru was performed, and revealed evidence of malrotation. The patient immediately underwent an uncomplicated exploratory laparotomy and surgical correction for malrotation.

Discussion: The diagnosis was delayed as a result of cognitive biases.  The pediatrician suspected intussusception in a newborn infant based on pattern recognition. This is an example of failed heuristic that is due to base-rate neglect. Intussusception is prevalent in infants older than 6 months. The framing effect, diagnosis momentum and ascertain bias induced different physicians to investigate the case in the wrong direction. The equivocal findings did not shift the diagnosis momentum as the teams already anchored to the initial diagnosis. Malrotation with midgut volvulus must be ruled out in all newborn infants with bloody stool because of its life-threatening complications. A simple rule of thumb, worse-case scenario approach, or diagnostic pause could have prevented this delayed diagnosis.