Sphacelus of the liver: an unexpected finding at autopsy
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DIFFERENTIAL DIAGNOSIS
Sphacelus of the liver: an unexpected finding at autopsy Martin Janı´k • Frantisˇek Novomesky´ Lubomı´r Straka • Petr Hejna
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Accepted: 23 October 2014 Ó Springer Science+Business Media New York 2014
Case report The death of a 50-year-old man was referred to our institute for autopsy evaluation as it was sudden and unexplained. The information given to the forensic pathologist included chronic alcoholism and a 4-week history of non-specific abdominal pain, weight loss, and progressive fatigue. External examination of the body revealed a distended abdomen and an inconspicuous, well-healed, 1.2 9 0.2 cm linear scar in the lateral part of the right upper abdominal quadrant (Fig. 1a, b). Reflection of the skin and subcutaneous tissue beneath the scar revealed a pyogenic abscess of the abdominal wall with softened, darkly colored edges (Fig. 1c, d). The abscess cavity apparently communicated with the peritoneal cavity. Opening of the peritoneal cavity revealed 700 ml of cloudy fibrinopurulent liquid with fibrinous adhesions between the bowel loops and greater omentum, consistent with generalized bacterial peritonitis. Further abdominal examination showed a destructive, necrotizing, well-demarcated process within the liver tissue, extending from the capsule to the adjacent subcapsular tissue of the right liver lobe (Fig. 2a, b). These changes were highly suggestive of humid gangrene, also known as sphacelus. Additionally, the lateral aspect of the right liver lobe revealed a relatively shallow, oval defect that penetrated
1.2 cm into the parenchyma (Fig. 2b). Examination of the pleural cavities disclosed a small quantity of bloodstained serous liquid. The lung tissue exhibited diffuse mild edema and congestion. Microscopically, destructive suppurative inflammation accompanied by confluent areas of hepatocyte necrosis and parenchymal collapse were throughout the liver tissue. Neither alcohol nor any other drugs were detected via toxicological studies. As the manner of death remained unclear, the decedent´s relatives were interviewed. After thorough questioning, it was concluded that the deceased fell onto a sharply pointed spiral plant stick that resulted in a seemingly insignificant wound to the right abdomen several days before the onset of the first abdominal symptoms. Immediately following injury, he was taken to a local hospital, where a clinical diagnosis of abdominal wall stab-like injury was made. The wound was locally managed and as the clinically stable patient declined further diagnostic intervention, he was discharged on the same day. The cause of death was determined to be gangrene of the liver associated with generalized peritonitis due to a remote penetrating abdominal injury. The manner of death was accidental.
Discussion M. Janı´k F. Novomesky´ L. Straka (&) Institute of Forensic Medicine and Medicolegal Expertises, Jessenius Faculty of Medicine, Comenius University, University Hospital, 036 59 Martin, Slovak Republic e-mail: [email protected] P. Hejna Departme
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