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Findings at anatomical dissection. a – Aorta opened from posterior aspect at the time of autopsy, demonstrating the aortic graft with the area of dehiscence from the wall of the aorta (at the level indicated by the red arrow). b – Aorta and adherent duodenum, post-formalin fixation and cut in cross-section along length of aorta, demonstrating within the length of the grafted segment, the aorta eroded into the duodenum creating an aortoenteric fistula between the native aorta and duodenum (fistula - red arrow; duodenum outlined by arrowheads). c – Aorta, post-formalin fixation and opened from posterior aspect, demonstrating that in the context of dehiscence of the aortic graft, a conduit existed between the aortic lumen and the duodenum, with blood passing through the dehiscence into the space between the aortic graft material and native wall (path demonstrated by probe, red arrow), then exiting into the GI tract via the aortoenteric fistula (the fistula to duodenum is not demonstrated with this view, see Fig. 2b)
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Secondary aortoduodenal fistula (AEF), although less rare than its primary form, is an uncommon and frequently lethal cause of gastrointestinal (GI) bleeding. We report a case of fatal GI hemorrhage in a woman with a remote history of endovascular graft repair of an abdominal aortic aneurysm. Postmortem examination included computed tomography (PMC...
Citations
... As the endoscopic examination is not practical after death and autopsy is not performed in all cases of death, previous case reports indicated the capability of noncontrast-enhanced or contrast-enhanced PMCT to identify the gastrointestinal bleeding site [9,12,13]. The role of an increased CT density in gastrointestinal contents has been emphasized in UGIB diagnosis. ...
This study aimed to establish the diagnostic criteria for upper gastrointestinal bleeding (UGIB) using postmortem computed tomography (PMCT). This case-control study enrolled 27 consecutive patients with autopsy-proven UGIB and 170 of the 566 patients without UGIB who died in a university hospital in Japan after treatment and underwent both noncontrast PMCT and conventional autopsy between 2009 and 2020. Patients were randomly allocated to two groups: derivation and validation sets. Imaging findings of the upper gastrointestinal contents, including CT values, were recorded and evaluated for their power to diagnose UGIB in the derivation set and validated in the validation set. In the derivation set, the mean CT value of the upper gastrointestinal contents was 48.2 Hounsfield units (HU) and 22.8 HU in cases with and without UGIB. The optimal cutoff CT value for diagnosing UGIB was ≥27.7 HU derived from the receiver operating characteristic curve analysis (sensitivity, 91.7%; specificity, 81.2%; area under the curve, 0.898). In the validation set, the sensitivity and specificity in diagnosing UGIB for the CT cutoff value of ≥27.7 HU were 84.6% and 77.6%, respectively. In addition to the CT value of ≥27.7 HU, PMCT findings of solid-natured gastrointestinal content and intra/peri-content bubbles ≥4 mm, extracted from the derivation set, increased the specificity for UGIB (96.5% and 98.8%, respectively) but decreased the sensitivity (61.5% and 38.5%, respectively) in the validation set. In diagnosing UGIB on noncontrast PMCT, the cutoff CT value of ≥27.7 HU and solid gastrointestinal content were valid and reproducible diagnostic criteria.
... Postmortem computed tomography (PMCT) has been widely used to determine the cause of death in forensic practice, and this method has obvious advantages for the diagnosis of bone injuries [1][2][3][4]. Previous studies showed that although PMCT has some limitations in the diagnosis of cardiovascular diseases, postmortem computed tomography angiography (PMCTA) is frequently applied to address such issues [3,[5][6][7]. Even so, the diagnostic value of PMCT for soft tissue and craniocerebral injuries is still relatively limited [3]. ...
Whiplash injury is common in traffic accidents, and severe whiplash is characterized by cervical spinal cord injuries with cervical dislocation or fracture, that can be diagnosed by postmortem computed tomography (PMCT), postmortem magnetic resonance (PMMR), or conventional autopsy. However, for cervical spinal cord injury without fracture and dislocation, PMMR can be more informative because it provides higher resolution of soft tissues. We report the case of a 29-year-old male who died immediately following a traffic accident, in which the vehicle hit an obstacle at a high speed, causing deformation of the bumper and severe damage of the vehicle body. PMCT indicated no significant injuries or diseases related to death, but PMMR showed patchy abnormal signals in the medulla oblongata, and the lower edge of the cerebellar tonsil was herniated out of the foramen magnum. The subsequent pathological and histological results confirmed that death was caused by medulla oblongata contusion combined with cerebellar tonsillar herniation. Our description of this case of a rare but fatal whiplash injury in which there was no fracture or dislocation provides a better understanding of the potentially fatal consequences of cervical spinal cord whiplash injury without fracture or dislocation and of the underlying lethal mechanisms. Compared with PMCT, PMMR provides important diagnostic information in forensic practice for the identification of soft tissue injuries, and is therefore an important imaging modality for diagnosis of whiplash injury when there is no fracture or dislocation.
... 29,89 Previous aortic reconstructive surgery is the most reported risk factor associated with an ADF, showing incidence rates that range between 0.04% up to 1%, whereas the mortality rate amounts to 80-100%. 90, 91 Gershon et al. 92 postulated postmortem imaging criteria that support the diagnosis of lethal ADF, which are based on: ...
Sudden and unexpected deaths due to non-traumatic abdominal disorders are a disregarded topic in the forensic field. These conditions are very heterogenous, accounting for 1–5% of sudden deaths. Specifically, acute gastrointestinal hemorrhages, bowel obstructions, liver cirrhosis, and necrotizing pancreatitis are frequently reported, whereas there are also unusual conditions which deserve careful analysis. Furthermore, the postmortem examinations of such disorders are not straightforward in the forensic setting since advanced putrefaction of the body, alleged medical malpractice, or the absence of any medical records could complicate autopsy procedures. Thus, the use of forensic histopathology, toxicology, microbiology, and postmortem radiology may help the pathologists to identify the abdominal cause of death. In this paper, the authors aim to discuss most of congenital and acquired abdominal conditions that have resulted in sudden and unexpected deaths. Hence, the discussion of the pathological features of each abdominal organ or system is prefaced with practical examples from caseworks of the Milan Institute of Legal Medicine. However, this paper also shows an extensive literature review with selected medicolegal articles to detailly describe the lethal mechanisms related to each condition, along with any associated risk factors or other diseases. Finally, each section shows a focus on either novel forensic approach (when available) or medicolegal implications, such as the use of postmortem radiology, peculiar histopathologic findings, or allegations in medical malpractices.
... PMCT is a valuable tool for the diagnosis of gastrointestinal bleeding. Hyperdense stomach and/or intestine content, usually with clot formation, is the main finding [62][63][64] (Figure 2). Differentiation of blood clots from other hyperdense stomach contents might be challenging in some cases. ...
Radiological findings of natural causes of death in adults in postmortem imaging are of enormous value for medicolegal investigation. Postmortem computed tomography (PMCT) in particular is increasingly used as a triage tool after external inspection and before a full autopsy.
Forensic pathologists and radiologists commonly deal with a wide variety of deaths from natural causes. The most common encountered natural causes of death refer to the cardiovascular, central nervous, respiratory, gastrointestinal and metabolic system.
This review provides an overview of the literature on postmortem imaging of the major natural causes of death in adults, categorized by organ systems.
This case report presents the sudden and unexpected death of a previously healthy young male, where investigations at the scene showed signs of upper gastrointestinal bleeding with hematemesis and melaena. The forensic autopsy revealed a Dieulafoy lesion in the esophagus as the source of bleeding. The Dieulafoy lesion is a rare cause of upper gastrointestinal bleeding with a large-caliber submucosal artery protruding into the lumen through a small mucosal defect, predominantly located in the stomach and less commonly in the esophagus.
