ALCOHOL RELATED DEATH

Introduction

Alcohol (ethanol or ethyl alcohol) is the

world’s favorite recreational drug, legally
available to adults and widely used for
pleasure and relaxation without
consequence.

However, ethanol is also a drug of abuse

and chronic drinking eventually leads to
dependence with serious consequences for
the individual and society.
CIRCUMSTANCES of death following alcohol abuse:
1. Accidents (trauma)
- Road traffic accidents
- Falls
- Drowning (lake/river/swimming pool etc.,)
- Postural (asphyxia)
- Methyl alcohol poisoning
2. Suicide
- Poisoning
- Hanging
3. Homicide
-Assault
4. Natural (diseases)
- Liver / Heart / Brain / Lungs / Pancreas / Kidneys

- General causes
- Anaemia / malnutrition
- Infectious disease
Heavy drinking suppresses the immune
system, providing a toehold for infections,
including tuberculosis, pneumonia,
HIV/AIDS, and other sexually transmitted
diseases
- Malignancy – Mouth, throat, Liver, Colon, Breast
- Hypoglycemia
- Hypothermia
- High blood pressure
5. Alcohol overdose
and
- Alcohol + Narcotics
- Alcohol + cigarettes smoking

6. Alcohol withdrawal – convulsion

and coma.
ACCIDENTS (TRAUMA)
Postural asphyxia (Positional
asphyxia)
a) Sleeping at the edge of bed /
Chair / Bench.
b) Fallen in to a pit or gutter under
influence of alcohol.
 Head law position
 diaphragm pull down
↓ed size of the chest cavity
 respiratory embarrassment.
 Methyl Alcohol Poisoning
Methanol  (alcohol dehydrogenase)
Formaldehyde  (oxidise) 
 Formic acid

Formic acid can not be detoxified.

Can develop severe acidosis.
Death can occur within 5 hours.
(Ethenol - >oxidized in the liver by alcohol dehydrogenase to form acetaldehyde, and this is
further metabolized to acetate (acetic acid) )
• Falls
• Drowning

• Suicide - Poisoning,Hanging
• Homicide - Head injury (blunt)
- Stabs and cuts
• Overdose
• Withdrawal
Diseases associate with
alcohol and Death
Most deaths (75%) showed evidence of potentially
alcohol-related pathologies, and 32% had pathologies
in two or more organs.

The liver was most commonly affected followed by the

lungs, stomach , pancreas, heart , brain and
oesophagus. Only a minority with liver pathology had a
second pathology.
Pathology of alcoholic liver
disease
- Fatty liver
- alcoholic hepatitis
- cirrhosis

Those are often considered separate,

progressive manifestations of alcoholic liver
disease.

However, their features often overlap.

Fatty liver (steatosis) is the initial and most common
consequence of excessive alcohol consumption. Fatty
liver is potentially reversible.

Macrovesicular fat accumulates as large droplets of

triglyceride and displaces the hepatocyte nucleus, most
markedly in perivenular hepatocytes.

The liver is enlarge.

Alcoholic hepatitis (steatohepatitis) is a combination of
fatty liver, diffuse liver inflammation, and liver necrosis
(often focal)—all in various degrees of severity.

The damaged hepatocytes are swollen with a granular

cytoplasm (balloon degeneration) or contain fibrillar
protein in the cytoplasm (Mallory or alcoholic hyaline
bodies).
Severely damaged hepatocytes become necrotic.
Sinusoids and terminal hepatic venules are narrowed.
Cirrhosis may also be present.
Alcoholic cirrhosis is advanced liver disease
characterized by extensive fibrosis that disrupts the
normal liver architecture.

The amount of fat present varies. Alcoholic hepatitis

may coexist. The feeble compensatory attempt at
hepatic regeneration produces relatively small
nodules (micro nodular cirrhosis).

As a result, the liver usually shrinks. In time, even

with abstinence, fibrosis forms broad bands,
separating liver tissue into large nodules (macro
nodular cirrhosis).
Alcoholic liver cirrhosis:
• Leading to liver failure.

• Portal hypertension  rupture of oesophageal

varices  Bleeding in to GIT tract.

• Primary liver cell carcinoma.

• Ascites / infections / Spontaneous bacterial

peritonitis.

• Hepatic encephalopathy.

• Hepatorenal syndrome.
Heart: Alcoholic heart disease
• Drinking alcohol in large quantities has a toxic
effect on the heart.

• Alcoholic cardiomyopathy is a form of a

condition in which the heart becomes
enlarged and the heart muscle thins (dilated
cardiomyopathy) due to alcohol abuse.
• Heavy drinking can cause cardiomyopathy, a
potentially deadly condition in which the heart
muscle weakens and leading to heart failure , as
well as heart rhythm abnormalities such as atrial
and ventricular fibrillation.

• Atrial fibrillation, can cause blood clots that can

trigger a stroke.

• Ventricular fibrillation causes rapid loss of

consciousness and, in the absence of immediate
treatment, causing sudden death.
Alcohol also causes arrhythmias
during life, including prolongation
of the QT interval, which is
associated with sudden cardiac
death.
Heavy consumption of alcohol is a
major cause of hypertension, so that
the diseases related to hypertension,
such as stroke, are generally related to
alcohol consumption.

Alcohol also causing myocarditis.

Brain: Hepatic encephalopathy
• Cerebral Cortical and White Matter Lesions.

• It is caused by liver failure due to chronic liver

disease, commonest of that is alcoholic
cirrhosis.

• usually due to high levels of serum ammonia.

Alcoholic encephalopathy:
Wernicke–Korsakoff syndrome (WKS).
It is a manifestation of thiamine(vitamin B1)
deficiency.

It mainly causes vision changes, ataxia and

impaired memory.
Brain atrophy occurs in the following regions of the brain;
( due to Thiamine deficiency)
- mamillary bodies
- thalamus
- cerebellum
- frontal lobe

- cortex - direct toxic effects of alcohol

Alcohol-thiamine interactions:
- Strong evidence suggests that ethanol interferes directly
with thiamine uptake in the gastrointestinal tract.

- Ethanol also disrupts thiamine storage in the liver and

the transformation of thiamine into its active form.
The mammillary bodies are a pair of small
round bodies, located on the under surface of
the brain.

Damage to the mammillary bodies due

to thiamine deficiency is implied in
pathogenesis of Wernicke-Korsakoff syndrome.

(vision changes, ataxia and impaired memory ).

Brain atrophy 
Chronic subdural
haemorrhage
Seizures

Heavy drinking can cause epilepsy and

can trigger seizures even in people
who don't have epilepsy.

It can also interfere with the action of

the medications used to treat
convulsions.
 Lungs: Alcoholic lung disease
• Is a disease of the lungs caused by
excessive alcohol consumption.

• Chronic alcohol ingestion impairs multiple

important cellular functions in the lung.

• These cellular impairments lead to increased

susceptibility to serious complications from lung
disease.
- Pneumonia
occurs due to an infection in the
lungs.
Those who have alcoholic lung disease
are believed to be more susceptible to
this type of infection.

- Acute Respiratory Distress Syndrome

(ARDS) is considered a medical
emergency because it can so easily
lead to death.
 Pancreas: Alcoholic pancreatitis
• Both types of pancreatitis can be caused by heavy
drinking.
If you drink regularly, you increase you risk of
developing pancreatitis.
Acute:
• Scientists aren’t sure exactly how alcohol causes
the condition. One theory is that the molecules in
alcohol interfere with the cells of the pancreas,
stopping them working properly.

• Whatever the cause, there is a clear link between

drinking alcohol and acute pancreatitis – and the
more alcohol you drink, the higher your risk of
developing the condition .
Chronic Pancreatitis:

• You’re more likely to have repeated episodes of acute

pancreatitis when you drink heavily. Over time, this will
cause permanent damage to your pancreas, causing
chronic pancreatitis. Around seven out of 10 cases of
chronic pancreatitis are due to long-term heavy drinking.

• And it’s worse if you smoke. Cigarettes are thought to

increase the harmful effects of alcohol on the pancreas.

• Gallstones (small stones, usually made of cholesterol that

form in the gallbladder) are another major cause of both
types of pancreatitis.

acute/chronic pancreatitis, diabetes

mellitus and pancreatic cancer.
Kidney:
Acute renal failure in a patient
suffering from chronic alcoholism

Chronic alcohol abuse may be

associated with UTI and/or papillary
necrosis, thus predisposing to an
increased risk of ARF.
Investigation of a death due to alcoholic
poisoning:
1. History

2. Scene - Position of the body

- Blood stains, patches
- Suicidal notes
- Bottles of alcohol, drugs, cigarettes
- Weapons
- Room arrangements – untidy etc.,

3. Autopsy examination - Clothing

- External features
- Internal features

4. Laboratory investigations - Toxicology

- Blood, urine, stomach
contents, vitreous humour
- Histology from all organs
Post-mortem features

Externally:
- Sings of neglect / dirty cloths with or without stains
- Healed and healing ulcers / skin diseases / muscle
wasting
- Jaundice
- Enlarged parotid glands
- Gynaecomastia
- Spider neavi
- Caput medusae
- Loss of axillary and pubic hair
- Testicular atrophy
- Haemorrhoids
- Ankle oedema
Internally:

1. Head - Sub dural haemorrhage

- Cerebral atrophy

2. Chest - Heart - dilated type cardiomyopathy / less fat

- Lungs - lobar / bronco Pneumonia, Tuberculosis, ARDS

3. Abdomen - Oesophageal varices

- Omentum - fat necrosis
- Stomach - chronic gastritis
- peptic ulcer / blood
- Intestine - blackish stools
- Liver - fatty, cirrhosis, tumour
- Spleen - enlarge / firm
-Pancreas - acute or chronic inflammation /
haemorrhage
- Kidneys - congested and swollen
Postmortem Samples:
The recommended sampling site for blood in postmortem
toxicology is a femoral vein.

For longer delays and when specimens are sent by mail to

another laboratory, it is imperative to include sodium or
potassium fluoride as a preservative in blood.

The fluoride ion functions as an enzyme inhibitor and prevents

the synthesis of ethanol by fermentation processes after
sampling.
Alternative Body Fluids

In postmortem work in addition to cardiac or femoral

venous blood,
urine, VH, and cerebrospinal fluid (CSF) are the most
useful specimens for determination of ethanol.