Pancreatitis: A Forensic Perspective

Do Not Turn a Blind Eye on Forensic Biochemistry: Using Vitreous Electrolytes to Reveal Renal Insufficiency as Cause of Death

ABSTRACT

In both medical and forensic autopsy, the kidneys may be overlooked grossly and histologically. As both acute and chronic kidney dysfunction have major implications on morbidity and mortality, it is essential to consider the kidneys as a pathologic source for both immediate and proximate cause of death. For decades, vitreous humor has been used as a measure of postmortem electrolyte analysis to help understand ionic disturbances carried over from the antemortem period. Renal insufficiency from both acute and chronic kidney dysfunction can be ascertained from vitreous investigations and should be a consideration for cause of death. Here, we present 4 cases in which vitreous analysis was used to determine the cause of death. In highlighting these cases, we support the use of biochemical testing in autopsy while demonstrating how it can help elucidate an often overlooked means of mortality. Importantly, it can help with the formulation of clinicopathologic correlations between antemortem and postmortem findings.

Diagnosis of Acute Pancreatitis Using Postmortem Computed Tomography and Postmortem Magnetic Resonance Imaging: A Case Report and a Review of Literature

ABSTRACT

Acute pancreatitis (AP) is inflammation of the pancreas, which may be due to a wide variety of etiologies that share a final common pathway of premature activation of pancreatic enzymes and resultant autodigestion of pancreatic parenchyma. Acute pancreatitis is easy to diagnose clinically, with the presence of at least 2 of the 3 criteria (upper abdominal pain, serum amylase or lipase level greater than 3 times the upper limit of normal, or characteristic findings on imaging studies) of the revised Atlanta classification. However, postmortem imaging examinations of pancreatitis are extremely rare, and very few successful cases have been reported. Here, we present a case report of a single patient who underwent autopsy and postmortem imaging. Postmortem computed tomography (PMCT) and postmortem magnetic resonance imaging (PMMRI) showed peripancreatic inflammation and acute peripancreatic fluid collection in the left anterior pararenal space, which is consistent with the examination by autopsy. The advantages of PMMRI in AP have also been demonstrated. Our study also confirmed the advantage of PMCT angiography in the diagnosis of AP. To the best of our knowledge, this is the first report of PMCT and PMMRI combined with postmortem pathology in the diagnosis of AP.

Diffuse, Adult-Onset Nesidioblastosis/Non-Insulinoma Pancreatogenous Hypoglycemia Syndrome (NIPHS): Review of the Literature of a Rare Cause of Hyperinsulinemic Hypoglycemia

Differential diagnosis of hypoglycemia in the non-diabetic adult patient is complex and comprises various diseases, including endogenous hyperinsulinism caused by functional β-cell disorders. The latter is also designated as nesidioblastosis or non-insulinoma pancreatogenous hypoglycemia syndrome (NIPHS). Clinically, this rare disease presents with unspecific adrenergic and neuroglycopenic symptoms and is, therefore, often overlooked. A combination of careful clinical assessment, oral glucose tolerance testing, 72 h fasting, sectional and functional imaging, and invasive insulin measurements can lead to the correct diagnosis. Due to a lack of a pathophysiological understanding of the condition, conservative treatment options are limited and mostly ineffective. Therefore, nearly all patients currently undergo surgical resection of parts or the entire pancreas. Consequently, apart from faster diagnosis, more elaborate and less invasive treatment options are needed to relieve the patients from the dangerous and devastating symptoms. Based on a case of a 23-year-old man presenting with this disease in our department, we performed an extensive review of the medical literature dealing with this condition and herein presented a comprehensive discussion of this interesting disease, including all aspects from epidemiology to therapy.

Sudden death related to the gastrointestinal system in Tunisia: A 13 year autopsy study

Sudden gastrointestinal (GI) death is an unexpected death due to digestive system causes mainly found after autopsy. The literature is rich in articles that studied sudden death due to cardiac causes while sudden GI deaths remain less well-documented. We retrospectively investigated all cases of gastrointestinal death at the Department of Forensic Medicine in Tunis, over 13 years (January 1, 2006 to December 31, 2018). Two hundred and eight cases were collected. The mean age of our series was 51.06 ± 20.99 years. No history of digestive disorders was reported in 78.4%, and no family history of sudden death was found in any cases. A male predominance was found in most epidemiological characteristics of the sample with a significant statistical rate in some features. Non-specific abdominal pain was the most described symptom (n = 92). Perforation of GI tract was the common mechanism involved in the death of 55 cases, of which 44 were related to ulcer perforation. These ulcer perforations were statistically more reported in smokers and people suffering from schizophrenia. Intestinal obstruction was the second commonest cause of death, mainly found in the elderly. Sudden death in children was most frequently caused by acute intussusception. This study highlights that systematic study of sudden death due to GI causes might provide opportunities to identify avenues for overall health improvement.

The Certification of Fatalities Related to Diabetes Mellitus: A Shot in the Dark?

Worldwide, an estimated 415 million people have diabetes mellitus, which results in extensive morbidity and mortality. In order to track the effect of diabetes on mortality statistics, deaths in which diabetes mellitus caused or contributed to death must be recognized, included on the death certificate, and then properly coded for vital statistic purposes. For public health policy, this will help determine the extent of the disease and follow whether deaths increase or decrease. There is variation among death certifiers for when and how diabetes is included on the death certificate and among vital records bureaus as how to code diabetes-related deaths. Case scenarios are presented to highlight the certification issues that arise with deaths related to diabetes mellitus. This area of death certification may benefit from a consensus effort to standardize and enhance certification and coding of deaths due to diabetes in order to improve the reliability of these mortality statistics.