Case Report on Sudden Death Due to Ruptured Esophageal Varices

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CASE REPORT

CASE REPORT ON SUDDEN DEATH DUE TO RUPTURED ESOPHAGEAL VARICES – AN AUTOPSY BASED DIAGNOSIS

Naveen Yadav∗,1, Luv Sharma∗, Kunal Gaba∗ and Sandeep Kumar Giri∗ ∗Department of Forensic Medicine, PGIMS, Rohtak, Haryana, India.

ABSTRACT Late presentation of many of the pathological conditions, leads to their in undiagnosed which culminating in sudden death. Among the various pathological conditions, gastrointestinal bleeding accounts for 10% of all sudden deaths among which oesophagal varices is an essential cause of bleeding and death. Here, we are presenting an undiagnosed case of esophageal varices that lead to the sudden death of an unknown male individual due to acute bleeding which was diagnosed later on autopsy.

KEYWORDS Sudden death, Esophageal varices, Bleeding, Cirrhosis

cases6. In the present case, an unknown male individual got admitted in an unconscious state with suggestive findings of upper GI bleed which remains undiagnosed during treatment Introduction and was confirmed at autopsy. Interesting findings of the case The World Health Organization defines sudden death as death are mentioned below. within 24 hours from the onset of symptoms.[1] 10% of sudden total deaths are related to the gastrointestinal causes.[2] Among Case report the various gastrointestinal causes, upper gastrointestinal bleeding is one of the most common cause. In upper gastrointestinal A passerby noticed that an unknown male individual was lying bleeding, esophageo variceal bleeding is a life-threatening con- unconscious near the sub-divisional magistrate residence of a dition. It is a well-known fact that the most common cause neighbouring district. He called an ambulance and the patient of esophageal varices in liver cirrhosis. Over 80% of patients was referred to tertiary care from the local hospital. The pa- with liver cirrhosis are likely to develop esophageal varices.[3] tient remained in the tertiary care center for about 12 hours but Acute bleeding or re-bleeding from ruptured esophagogastric as time was wasted on paper formalities, no proper diagnosis varices is one of the most severe complications of cirrhosis which was established and the patient died. The dead body was then culminate to sudden death[4]. Existing literature indicates that referred to our mortuary for autopsy. the mortality rate with variceal bleeding episode is 30-50%.[5] AUTOPSY FINDINGS Variceal hemorrhage is a medical emergency in which up to EXTERNAL FINDINGS: The dead body was of a poor built 20% of patients die due to hemorrhage refractory to standard young adult male individual. Both eyes were closed. The mouth treatment, either because of failed bleeding management or as was closed. The deceased looked markedly wasted, icteric and a result of early rebleeding, which may occur in nearly 70% of pale. Dried blood clots were present around the mouth. There was no evidence of struggle or violence marks on the body as Copyright © 2020 by the Bulgarian Association of Young Surgeons well as no sign of decomposition. DOI:10.5455/IJMRCR.esophageal-varices First Received: September 28, 2019 INTERNAL FINDINGS: Brain and lungs were edematous Accepted: December 08, 2019 and congested. Esophagus: The inner aspect of the lower one- Manuscript Associate Editor: Ivan Inkov (BG) third of esophagus showed multiple varices of varying size; few of them were ruptured. Tortuous blood vessels were present 1Dr. Naveen Yadav (PG Resident); Address: Department of Forensic Medicine, PGIMS, Rohtak (Haryana); Email: [email protected] over the lower half of the esophagus which was later confirmed by microscopy. [Figure 1]

Naveen Yadav et al./ International Journal of Medical Reviews and Case Reports (2020) 4(5):57-59 The stomach contained about 500 cc of reddish-brown liquid blood along with few clots. The mucosa was hyperemic at places. Externally brownish-black hue was present over the small intes- tine and contained brownish-black colored blood admixed with liquid chyme. [Figure 2] The liver was found adhered to the right dome of the di- aphragm. The surface of the liver was coarse with micronodules over it. Consistency of the liver was firm to hard and both, the outer and cut surface of the liver showed tan yellowish appear- ance [Figure 3]. Histopathological examination of the liver showed perivenu- lar and pericellular fibrosis, regenerating parenchymal nodules separated by dense bands of fibrosis, mild periportal inflamma- tion comprising of lymphocytes and plasma cells and hepato- cytes. Autopsy findings were confirmed by histopathological examination. [Figure 4]

Figure 2

Figure 1

Discussion Instead of returning directly to the heart, venous blood from the gastrointestinal tract is delivered to the liver via the portal vein before reaching the inferior vena cava. This circulatory pattern is responsible for the first-pass effect, in which the liver processes drugs and other materials absorbed in the intestines before en- tering the systemic circulation. Diseases that impede this flow cause portal hypertension, which can lead to the development of esophageal varices, an essential cause of esophageal bleeding. Thus, portal hypertension induces development of collateral Figure 3 channels that allow portal blood to shunt into the caval system. However, these collateral veins enlarge the subepithelial and submucosal venous plexi within the distal esophagus. These vessels termed varices, develop in 90% of cirrhotic patients, most commonly in association with alcoholic liver disease. World- wide, hepatic schistosomiasis is the second most common cause of varices. Varices often are asymptomatic, but their rupture can lead to massive hematemesis and death. Variceal rupture, therefore, constitutes a medical emergency. Despite the interven- tion, as many as half of the patients die from the first bleeding episode, either as a direct consequence of hemorrhage or due to hepatic coma triggered by the protein load that results from intraluminal bleeding and hypovolemic shock. Among those who survive, additional episodes of hemorrhage, each poten- tially fatal, occur in more than 50% of cases. As a result, greater than half of the deaths associated with advanced cirrhosis result from variceal rupture.[7] Figure 4

Naveen Yadav et al./ International Journal of Medical Reviews and Case Reports (2020) 4(5):57-59 It is a well known fact that gastrointestinal causes contribute 6. Graham DY, Smith JL. The course of patients after variceal about 10% of cases of sudden death. In gastrointestinal causes hemorrhage. Gastoenterology. 1981; 80:800- 9. bleeding due to esophageal rupture is one of the most common cause2. The similar ﬁndings cause sudden death due to rupture 7. Kumar V, Abbas AK, Aster JC. Robbins and Cotran patho- of esophageal varices is noted by the many authors. logic basis of disease 10th ed. Philadelphia, PA: Else- In a study by Sharma et al., a 48 years old male individual was vier/Saunders. 2018:591. found unconscious at his workplace. After admission in hospital 8. Ossei PPS, Duah EA, Duduyemi1 MB, Titiloye1 NA, Brefo and before the establishment of diagnosis, he succumbed to EA and Fenteng. Esophageal Varices from Alcohol-Induced death. He was a chronic alcoholic and esophageal varices were Liver Cirrhosis: Autopsy-Based Case Study of Morphologic diagnosed on autopsy[4]. Changes of Organs. J Forensic sciences and criminal inves- In another case report by Ossei et al., a 53 years old male tigation. 2017; 5(5) individual with a history of chronic alcoholism, was reported to have been found dead in front of his room at the lawn. The 9. Shetty BSK, Rastogi P, Kanchan T, Palimar V. Postmortem diagnosis of death due to massive haemorrhage due to rupture diagnosis of esophageal variceal bleeding – a case of sudden of esophageal varices was made at autopsy[8]. death. Journal of Punjab Academy of Forensic Medicine Shetty et al.[9] reported a case in which a seventy years old, and Toxicology. 2009;9. male, a manual labourer by occupation suddenly had episodes of vomiting of blood and then collapsed on to the ground while he was on his way to work. The root cause of bloody vomiting was made out during autopsy i.e. rupture of oesophageal varices. He had a history of chronic alcohol consumption. There are many cases reported by different authors that many individuals died due to esophageal variceal bleeding. Many individuals who were chronic alcoholics and in most of the cases individuals died before getting the proper diagnosis and treatment, and most of the cases were diagnosed on the autopsy table. The actual number of such fatalities must be much more than those reported.

Conclusion Alcohol abuse has a crushing impact on human lives particu- larly in developing nations. In alcoholics, screening related to the condition of liver or cirrhotic changes should be mandatory and patients in which cirrhotic changes are present prophylactic measures should be taken to avoid sudden death due to haem- orrhagic shock. The possibility of esophageal varices should be kept in mind during the treatment, if there is history of hae- matemesis.

Conﬂict of interest The authors declare no conﬂict of interest.

References 1. Saukko P and Knight B. Knight’s Forensic Pathology. 3rd ed. London: Arnold, 2004:527-541.

2. Vij K. Text Book of Forensic Medicine and Toxicology. 3rd ed. New Delhi: Elsevier, 2005: 197-215.

3. Zhuang ZH, Lin AF, Tang DP, Wei JJ, Liu ZJ, et al. (2016) Association of Endoscopic Esophageal Variceal Ligation with Duodenal Ulcer. Journal of the College of Physicians and Surgeons–Pakistan: JCPSP, 26(4): 267- 271.

4. Sharma A, Barwa J. Sudden death due to rupture esophageal varices a case report. J Punjab Acad Forensic Med Toxicol 2010; 10 (2).

5. Chalasani N, Kahi C, Francois F, Pinto A, Marathe A, et al. (2003) Improved patient survival after acute variceal bleeding: A multicenter cohort study. Am J Gastroenterol 98: 653-659.

Naveen Yadav et al./ International Journal of Medical Reviews and Case Reports (2020) 4(5):57-59