On April 21, 2008, plaintiffs’ decedent Jorge Juarez, 58, an auto mechanic, presented to Gustavo Machicado, M.D., an internist and gastroenterologist, for a colonoscopy for screening purposes, although he had no known history of colon cancer and a recent complete blood count ruled out anemia. The “post-operative diagnosis” section of the colonoscopy report indicated that the study was extremely limited due to poor bowel preparation. The report also stated that the cecum, parts of the ascending colon, and parts of the descending colon could not be well visualized due to the presence of solid stool. Notwithstanding this documentation, Machicado stated in his report that, in general, there was no evidence of any polyps, mass lesions or mucosal lesions. In addition, a digital rectal examination done as part of the colonoscopy procedure failed to reveal any suspicious masses. Based on these findings, Juarez was advised to have annual hemoccults and to return in five years for a repeat study. The subject colonoscopy was the only involvement Machicado had with Juarez’s care. In August 2009, Juarez had a negative hemoccult test and a negative CT of the abdomen. A prostate biopsy was then performed in late 2009, and there were apparently no findings at that time of a suspicious rectal mass. Thus, with an exception of a report of abdominal bloating in April 2010, Juarez remained without gastrointestinal symptoms until October 2010, when he complained of left upper quadrant pain. On Jan. 13, 2011, the plan was to perform a follow-up colonoscopy, but due to a large obstructive mass in the rectum, the gastroenterologist could not pass the colonoscope. As a result, an esophagogastroduodenoscopy and flexible sigmoidoscopy was done instead, and biopsies were taken from the area of the rectal tumor. On Jan. 20, 2011, a CT scan of the abdomen and pelvis revealed a rectal and cecal mass with evidence of metastatic encasement of other areas of the colon. Juarez then underwent a loop colostomy on Jan. 25, 2010, and pathology results from this procedure revealed the presence of signet ring cell cancer in the rectum and metastatic peritoneal involvement. On Feb. 8, 2011, Juarez underwent a gastrografin study, which showed irregular narrowing of the proximal transverse colon consistent with an apple core lesion, and a repeat colonoscopy was positive for a tumor in the right colon. However, pathology submitted from the colonoscopy was negative for malignancy. On May 23, 2011, Juarez passed away from metastatic colorectal cancer. The decedent’s wife, Ana Arevalo, and the decedent’s children, Katia Juarez, Alberth Juarez, Karla Juarez and Kayleen Juarez, sued Machicado. The decedent’s family alleged that Machicado failed to timely diagnose the decedent’s colorectal cancer and that his failure constituted medical malpractice. One of the decedent’s offspring, Kenia Bonilla, was named as a nominal defendant, but did not appear and a default judgment was entered. The plaintiffs’ gastroenterology expert testified that Machicado fell below the standard of care by not bringing the decedent back for a second colonoscopy after the first study was noted to be incomplete due to the presence of stool. The expert’s interpretation of Machicado’s report was that it was extremely limited due to poor preparation and he opined that the standard of care under this circumstance was to have the patient return within a few months to allow for better visualization of the right colon, including the cecum. He also opined that Machicado failed to adequately evaluate the rectum with the colonoscope. The expert gastroenterologist opined that Machicado missed a polyp in the cecum and rectum, as there was a subsequent finding of a “cecal mass” and a primary tumor in the rectum. The plaintiffs’ oncology expert testified that at the time of the subject colonoscopy in 2008, the decedent had synchronous polyps in the rectum and cecum. He opined that the cancer in the cecum subsequently metastasized to the peritoneum and caused the decedent’s death. The expert testified that the opinion that the decedent, indeed, had a primary cancer in the cecum was based on subsequent findings of a tumor in the cecum during the follow-up colonoscopy and during a laparoscopic procedure wherein the surgeon noted a hard mass in the cecum. The plaintiff’s oncology expert opined that based on the size of the cecal tumor when the decedent’s was diagnosed with colorectal cancer in early 2011, the tumor had to have been present for 2.5 to three years. He further opined that had the cecal polyp been discovered at the 2008 colonoscopy, it would have been removed, preventing the decedent’s death. The defense’s expert gastroenterologist’s interpretation of the subject colonoscopy report was that despite poor preparation, Machicado was able to sufficiently visualize all areas of the colon, including the cecum, and properly documented that there was no evidence of masses or mucosal lesions. The expert testified that five to 10 percent of patients present for their colonoscopies with poor preparation and that gastroenterologists are trained to irrigate, suction and/or reposition the patient in order to move stool around to allow for adequate visualization. Although these maneuvers were not documented in Machicado’s colonoscopy report, the defense’s gastroenterology expert opined that since they are so routine, there would have been no need to have done so. Thus, the expert opined that under the circumstances of a negative colonoscopy in a patient with no family history of colon cancer and a normal CBC, it was within the standard of care to recommend to the patient to undergo yearly hemoccults with his primary care physician and to return for a repeat colonoscopy in five years or sooner, if indicated. The defense’s oncology expert testified that the pathology reports from biopsies taken from the rectum and peritoneum, subsequent to the subject colonoscopy, indicated that the primary signet ring cell cancer in the rectum metastasized to the peritoneum in the area of the transverse colon and right colon, as well as to other scattered areas in the gastrointestinal tract. He also testified that given the aggressive nature of this type of cancer, more likely than not, the cancer did not begin to develop until two years or less before the time of the diagnosis in January 2011. Thus, the oncology expert opined that the decedent’s clinical course (lack of symptoms and negative studies) during the time period between 2008 and October 2010 was consistent with the theory that the rectal cancer did not begin until well after the subject colonoscopy. He also opined that these type of patients most often do not present until their cancer has advanced to Stage III or IV. The expert further opined that Juarez did not have a primary tumor in the mucosa of the cecum since multiple biopsy samples from this area failed to reveal cancer. Thus, he opined that the appearance of a mass-like lesion in the cecal area on imaging studies and report colonoscopy was due to extrinsic metastatic lesions that encased the colon and resulted in narrowing of the lumen. The defense’s pathology expert testified that the pathology slides containing samples taken from the decedent’s rectum and peritoneum during a Jan. 25, 2011 surgical procedure revealed findings consistent with a primary signet ring cell tumor in the rectum and evidence of the same cancer having had metastasized to the peritoneum. The expert testified that this type of cancer does not have a “polyp phase,” as it begins as a flat lesion in the mucosa and progresses rapidly to metastatic disease. He also testified that screening colonoscopies have not been shown to reduce the mortality of these types of patients. In regard to the cecal mass or tumor observed during the 2011 colonoscopy, the defense’s pathology expert testified that the only way to confirm that it was a primary mucosa cancer would be by way of pathology findings. He further testified that, typically, the gastroenterologist who observes a mass during a study will take samples from the mucosa that appears to be most suspicious for cancer, but that in this case, eight samples were taken by the gastroenterologist who performed the 2011 colonoscopy and none of them were diagnostic of malignancy., Jorge Juarez was diagnosed with signet ring cell cancer of the rectumwith metastatic peritoneal involvement on Jan. 25, 2010. A repeat colonoscopy was also positive for a tumor in the right colon, but the pathology was negative for malignancy. However, Juarez ultimately passed away from metastatic colorectal cancer on May 23, 2011. He is survived by his wife and children. Thus, the decedent’s family sought recovery of wrongful death damages.