Liver Tissue Embolism in the Portal Vein

Liver tissue embolism in the portal vein

Masahito Hitosugi*, Arisa Takeda, Shiho Hiraizumi, Shingo Moriguchi

______Abstract: In practical forensic medicine, detecting embolisms is important for not only determining the cause of death but also suggesting vital reactions of the victim. We herein report the first autopsy case of a victim with liver tissue embolism in the portal vein. A healthy man in his 40s immediately died of chest compression by the grinder of motor vehicle parts while working. Postmortem computed tomography and forensic autopsy revealed massive destruction of the bilateral ribcage, lung injuries, and massive liver injuries. Microscopically, apart from the injured region of the liver, injured liver tissue was impacted in the portal veins. Although bone marrow embolism or fatty embolism often occurs after severe trauma, these findings are difficult to detect if the intrathoracic pressure is high or the rib cage is massively injured, as in the present case. Therefore, examining embolisms at locations other than the pulmonary arteries is worthwhile for forensic pathologists to show vital reactions. In the present case, injured liver tissues were transported via the blood flow of the portal vein. Because such embolisms appear at uninjured sites of the liver, blood flow might be observed immediately after the injury. This case suggests new findings of a vital reaction following massive chest compression and the importance of microscopic analysis of injured patients. Key Words: liver tissue embolism, portal vein, chest injury, liver injury, vital reaction.

INTRODUCTION herein report the first autopsy case of a victim with liver tissue embolism in the portal vein. In practical forensic medicine, pulmonary embolisms are often seen and sometimes become a cause CASE REPORT of death. Pulmonary thromboembolism is the most common type of pulmonary embolism; bone marrow A man in his 40s with no medical history had embolism (BME), fat embolism (FE), air embolism, worked in a factory, operating the grinder of motor vehicle amniotic fluid embolism, and cerebral tissue embolism parts. Another worker heard the warning alarm of the have also been reported [1-7]. Detection of these machine and approached it, finding that the man’s upper embolisms contributes to estimation of the survival time torso had been compressed by the machine. Although after injury [4, 5]. However, because BME and FE to the paramedics arrived and his body was released, he was in lung are well-known complications of cardiopulmonary cardiopulmonary arrest and was soon pronounced dead. resuscitation, these findings cannot be considered vital Postmortem computed tomography revealed multiple rib reactions of injuries if cardiopulmonary resuscitation has fractures with massive destruction of the right chest and been performed [2]. Cerebral tissue pulmonary embolism bilateral pleural effusion suggesting hemothorax (Fig. 1a, has been reported as a vital reaction following massive b). A forensic autopsy was performed the next day. head trauma [7]. To the best of our knowledge, however, The man was 174 cm high and weighed 74 kg. no other organ embolisms suggesting a vital reaction His skin was pale, and petechial hemorrhage was present have been reported in the field of forensic medicine. We on the bilateral conjunctivae. Externally, large abrasions

Shiga University of Medical Science, Department of Legal Medicine, Otsu, Japan * Corresponding author: Shiga University of Medical Science, Department of Legal Medicine, Tsukinowa, Seta, Otsu, Shiga 520-2192, Japan, Tel/Fax: +81-77-548-2200, E-mail: [email protected]

119 Hitosugi M. et al. Liver tissue embolism in the portal vein

Figure 2. Macroscopically, the upper part of the right lobe of the liver was massively destroyed and separated into three pieces.

in each rib, suggesting bilateral flail chest. The right lung was massively lacerated by the fragments of the fractured ribs, and left lung contusion was also found. The upper part of the right lobe of the liver was massively destroyed and separated into three pieces (Fig. 2). Fractures of the lumbar spinous process were also found. Microscopically, destruction of the lung tissue with massive hemorrhage of the pulmonary alveoli was Figure 1. Postmortem computed tomography revealed found. Neither BME nor FE was found in the pulmonary multiple rib fractures with massive destruction of the right arteries. Liver tissue destruction with surrounding chest and bilateral pleural effusion. hemorrhage was present (Fig. 3a). In the left lobe, and purple-brown–colored changes were found on apart from the injured region, injured liver tissues were the yielding anterior chest. A 13-cm-long laceration impacted in the portal veins (Fig. 3b, c). surrounded by abrasions was found on the right lateral Neither alcohol nor drugs were detected from side of the chest. A large quadrangle abrasion with a 21- the blood or urine by gas chromatography and gas cm laceration passing from right to left was found on chromatography/mass spectrometry. the back of the chest. Internally, massive hemorrhage Finally, the cause of death was determined to be was found in the subcutaneous tissues and muscles on bilateral lung injuries due to massive destruction of the the anterior and posterior aspects of the chest. The right bilateral rib cage by chest compression. Liver injury had 3rd to 9th ribs and the left st1 , 2nd, 4th to 8th, 10th, and 11th also occurred by destruction of the right rib cage. ribs were fractured with one to three fractured regions

a b c

Figure 3. Microscopic examination revealed (a) liver tissue injury (magnification ×100) and (b, c) liver tissue thrombi in the portal veins (b, magnification ×100; c, magnification ×200).

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DISCUSSION Because the chest was compressed and the thorax was subsequently destroyed, the injured liver tissues did In practical forensic medicine, embolisms are not reach the pulmonary artery. Although liver tissue often found in victims with trauma or non-critical illness embolism is a vital reaction that occurs immediately and sudden death. Because it refers to the transport of after injury, this phenomenon may depend on certain material in the bloodstream, this phenomenon becomes conditions. Formation of FE requires damage to fat tissue a vital reaction of the victim. Although BME or FE often stores, rupture of surrounding veins, and an increase in occurs following severe trauma [2], these findings are the local intestinal tissue pressure [3]. Therefore, further difficult to discern if the intrathoracic pressure is high or accumulation of cases involving liver tissue embolisms the thoracic rib cage is massively injured, as in the present is needed, and the underlying mechanism should be case. Therefore, examining embolisms at locations other analyzed. than the pulmonary arteries is worthwhile for forensic This is the first reported case of liver tissue pathologists to show a vital reaction. With respect to embolism in the portal vein. This case suggests new embolism of portal veins, portal vein thrombosis (PVT) findings of a vital reaction following massive chest has been reported. In one study of 23,796 pathological compression and the importance of microscopic analysis autopsies, the prevalence of PVT was 1.0% [8]. PVT was of injured patients. caused by a variety of conditions including cirrhosis, cancer, sickle cell disease, and abdominal infections Conflict of interest. The authors declare that such as hepatic amoebiasis [8-10]. The highest risk of there is no conflict of interest. PVT was considered to be present in patients with both Acknowledgment. We thank Angela Morben, cirrhosis and hepatic carcinoma [8]. Although PVT due DVM, ELS, from Edanz Group (www.edanzediting.com/ to treatment or surgical trauma has been reported, radio ac), for editing a draft of this manuscript. frequency ablation or hepatocytes transplantation, PVT Funding. This work was performed without has not shown after not surgical trauma [8, 11, 12]. funding support. In the present case, injured liver tissues were Ethical approval. This article does not contain transported via the blood of the portal vein. Because any studies with human participants or animals such embolisms are present in the uninjured liver, blood performed by any of the authors. flow might be observed immediately after the injury.

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