Journal of Punjab Academy of Forensic Medicine & Toxicology 9 (2009)

POSTMORTEM DIAGNOSIS OF ESOPHAGEAL VARICEAL BLEEDING

A CASE OF SUDDEN DEATH.
Dr. B. Suresh Kumar Shetty, Assistant Professors, Department of Forensic Medicine. Kasturba
College, Mangalore, India.
Dr. Prateek Rastogi, Assistant Professors, Department of Forensic Medicine. Kasturba Medical
Mangalore, India.
Dr Tanuj Kanchan, Assistant Professors, Department of Forensic Medicine. Kasturba Medical
Mangalore, India.
Dr Vikram Palimar, Assistant Professor, Department of Forensic Medicine. Kasturba Medical
Manipal, India.

Medical
College,
College,
College,

Abstract
Forensic pathologists role in the investigation of sudden unexpected deaths is vital. Most of
sudden unexpected deaths in the absence of violence, accidental, suicidal or conditions of death not
preceded by morbid symptoms form the subject of medico legal investigation if they occur suddenly in
apparently healthy person, wherein autopsy would shed light to the exact cause of death, i.e. whether it
is natural or unnatural. Here we present an uncommon case of an aged person who succumbed to
sudden death due to esophageal variceal bleeding.
Keywords: Esophageal varices; sudden death; cirrhosis.
2009 JPAFMAT. All rights reserved
Introduction
of portal hypertension associated with a
significantly higher mortality rate. Although a
large number of clinical studies have dealt with
the clinical management,
prognosis, and prophylaxis of bleeding
esophageal varices, a paucity of autopsy studies
have addressed the topic.[3] There is a definite
dearth of case reports regarding the
medicolegal aspects of fatal esophageal variceal
hemorrhage published in both national and
international journals. Therefore, the present
case report is highlightened in sudden,
unexpected death from esophageal variceal
hemorrhage diagnosed at medicolegal autopsy.

The WHO defines sudden death as

death within 24 hours from the onset of
symptoms but it is too long a time for many
clinicians and pathologists who accept deaths
within 1 hour from the onset of illness.[1]
Sudden deaths are mainly attributed to the
cardiovascular system; 45% of sudden deaths
are related to the cardiovascular system, 25% to
the respiratory system, 20% to the nervous
system and 10% due to other causes mainly
gastro intestinal.[2] Among the causes of
gastrointestinal bleeding, esophageal variceal
hemorrhage is a life-threatening complication

Case report

(Corresponding author)
Dr. B. Suresh Kumar Shetty
Phone: +919886092392
Email: sureshbshetty.2009@rediffmail.com

A seventy year old, male, manual labourer by

occupation suddenly complained vomiting of
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Journal of Punjab Academy of Forensic Medicine & Toxicology 9 (2009)

blood and then collapsed on to the ground

while he was on his way to work. Based on
information obtained from witness reports from
police file, we were able to establish that he
had a history of chronic alcohol consumption.
He died on the way to the hospital and post
mortem examination was conducted the same
day. On external examination, blood smears
were seen on the body surface resulting from
hematemesis. At the death scene, blood stains
with vomitus were found on the road. Autopsy
finding showed ruptured esophageal varices
that were located in the lower and middle third
of the esophagus with torturous vessels all
along the esophageal mucosa (Fig.1), confirmed
by microscopical examination.

Fig.2 Gastric contents showing frank blood

Discussion
Esophageal varices represent the most
important complication of portal hypertension
and arise from the opening of portosystemic
collaterals as an adaptation to decompress the
portal venous system. It is well established that
alcoholic liver cirrhosis is the primary factor in
the pathophysiology of portal hypertension,
findings support the current clinical concepts
that alcoholic liver cirrhosis is associated with a
significantly higher risk of variceal bleeding than
is cirrhosis arising from other causes[4] and the
prognosis for an individual patient, depending
on the severity of the bleeding episode and
underlying liver function, is generally poor in
patients with established cirrhosis and
hepatocellular carcinoma [5]. The present case
has a correlation of both variceal bleed and
alcohol.

Fig.1 Ruptured esophageal varices in the lower

and middle third with torturous vessels all along
the mucosa
Mallory-Weiss syndrome was ruled out
macroscopically. Gastric contents showed 1500
ml of frank blood (Fig.2). An alcoholic fatty
change of the liver was present with a known
history of chronic alcohol consumption. Spleen
was enlarged, brain and lungs were congested
and oedematous and kidneys were congested.
No other external /internal injuries were
present on the body. All other natural body
orifices were intact. Toxicological analysis was
negative for poisons. Death was attributed to
the rupture of esophageal varicies, a natural
cause of death.

Studies
suggest
that
ruptured
esophageal varices are responsible for 50% to
80% of upper gastrointestinal bleeding
episodes.[6,7] The observed frequency of 0.75%
of all deaths encountered in a medicolegal
autopsy population, fatal esophageal variceal
bleeding accounts for a larger proportion of
out-of-hospital deaths.[8,9]The number of fatal
gastrointestinal hemorrhages in younger
individuals occurring out of hospital is likely to
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Journal of Punjab Academy of Forensic Medicine & Toxicology 9 (2009)

3. Mathur SK, Vora IM, Supe AN, Plumber

ST and Naik SR. Morphological changes
in esophagus following endoscopic
sclerotherapy with 3% aqueous phenol.
Indian J Gastroenterol 1990; 9:213-215.
4. Kleber G, Sauerbruch T, Ansari H and
Paumgartner G. Prediction of variceal
hemorrhage in cirrhosis: a prospective
follow-up study. Gastroenterology
1991; 100:1332-1337.
5. McCormick PA and Burroughs AK.
Relation between liver pathology and
prognosis in patients with portal
hypertension. World Surg 1994;18:171175
6. Christensen E, Fauerholdt L, Schlichting
P, Juhl E, Poulsen H and Tygstrup N.
Aspects of the natural history of
gastrointestinal bleeding in cirrhosis
and the effect of prednisone.
Gastroenterology 1981; 81:944-952.
7. Tabibian N and Graham DY. Source of
upper gastrointestinal bleeding in
patients with esophageal varices seen
at endoscopy. I Clin Gastroenterol
1987;9: 279-282.
8. Raymond JR, van den Berg EK Jr and
Knapp MI. Nontraumatic prehospital
sudden death in young adults. Arch
Intern Med 1988; 148:303-308.
9. Logan RF and Finlayson ND. Death in
acute upper gastrointestinal bleeding:
can endoscopy reduce mortality?
Lancet 1976; 1:1173-1175.
10. Tsokos M and Schmoldt A. Contribution
of nonsteroidal anti-inflammatory drugs
to deaths associated with peptic ulcer
disease. Arch Pathol Lab Med 2001;
125:1572-1574.
11. EI-Serag HB and Everhart JE. Improved
survival after variceal hemorrhage over
an 11-year period in the Department of
Veterans Affairs. Am I Gastroenterol
2000; 95:3566-3573.

be underestimated from the clinical viewpoint

due to the under representation of such cases
in the field of clinical pathology.[10]The mean
ages of the outpatients depicted in one of the
study is substantially younger than the
inpatients presenting with acute esophageal
variceal hemorrhage.[11] These results also
explain that the deaths of younger individuals
taking place out of hospital are more often
subjected to a medicolegal autopsy than are the
deaths of older individuals that occur more
often inside hospital.[11] This finding is not seen
in present case, i.e. we have an old aged male
succumb outside the hospital.
From medico legal view point, we stress
that blood stains at the death scene and
unusual body positions of the deceased that
arouse suspicion of a violent death (i.e.
preceding blunt force) were one of the leading
reasons for conducting a medico legal autopsy
in such cases of fatal esophageal variceal
hemorrhage.Medico legal autopsy analyzes
sudden death in outpatients, which often lack
detailed information about the clinical picture
preceding death; therefore, conclusions are
mainly based on autopsy findings and police
reports. Nonetheless, the case report presented
here stresses at the importance of fatal
esophageal variceal hemorrhage as a relevant
cause of sudden death occurring outside the
hospital in socially isolated, alcohol-addicted
individual.
Conflict of Interest
None declared.

References
1. Saukko P and Knight B. Knights Forensic
Pathology. 3rd ed. London: Arnold,
2004:527-541.
2. Vij K. Text Book of Forensic Medicine
ed. New Delhi:
and Toxicology. 3rd
Elsevier, 2005: 197-215.

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