Dr Hugo Ford, Dr James Rudd, Dr Helen Simpson, Dr Prina Ruparelia and Dr Alison Cluroe, Addenbrookes Hospital
Dr Alison Cluroe begins the post-mortem by opening the abdomen to study the stomach, pancreas and kidneys with Chris Smith...
Chris - When one looks at a text book and you see a person drawing, you can see this very organised loops of bowel, but this does not look organised. Just before weíve even moved anything around, there seems to be stuff everywhere.
Alison - Yes, I think itís probably a bit like a personal fingerprint - no-one's is probably quite the same. But youíre right, it doesnít look anything like the text books.
Chris - Do you preserve the contents of whatís in the intestine?
Alison - Yes. So what youíre seeing here now is the technician is actually tying off the base of the stomach where it goes into the first part of the small intestine, and thatís to preserve the stomach contents should we need to analyse it. Sometimes we do in a case where weíre suspicious that the person might have taken an overdose, for example.
Chris - What you have in front of you, Alison, is a little table that youíve put over the gentleman's legs and, on top of that table, youíre putting each of the things that we have removed from inside his body. And so now, this is the process where youíre beginning to look at each of the organs in turn to step through them and see if thereís anything in there.
Alison - Thatís right. So, with my scissors Iím cutting down the gullet and into the stomach. Thereís quite a lot of brown liquid in the stomach and this is just likely to be fluid that the deceased gentleman has had prior to death. And the striking thing is that you can see those sort of little black spotty areas over the lining of the stomach hereÖ
Chris - Yes. The lining is sort of pale grey colour, and in some places itís not grey, itís like it'd got a rash - a very fine red rash. Why is that?
Alison - I think this gentleman has some gastric erosions. So these are very superficial damages to the lining of his stomach. That mucus there, when it breaks down, leads to stomach acids to be able to actually get to the lining of the stomach wall and cause ulceration and, hence, gastric ulcers. Thatís not uncommon in people who are very unwell.
Weíre going to move to some of the other abdominal organs now and the first one Iíve got here to look at is the pancreas. Now the pancreas lies just behind the stomach and it is an endocrine organ - that is an organ that produces hormones. It does two things actually, it produces insulin which, obviously, is useful in controlling our metabolism of sugars. And insulin is a substance that is in short supply in people with type 1 diabetes, where theyíre insulin dependent and need to have daily injections.
Chris - Itís what - 15-20 cms long this one, isnít it? And itís got a sort of bulbous end, a fist sized end, and then a tail coming of that, thatís a few cms across, and youíve cut slices from one end to the other right across it. What are you looking for?
Alison - Pancreatitis. Inflammation of the pancreas can be seen in people with gallstones, people who are heavy drinkers but this pancreas looks quite normal.
Chris - Put that to one sideÖ
Alison - Weíve got the two kidneys which are surrounded by a huge casing of fat. You can see, when I take this fat off youíll be surprised at how small the little kidneys are in size.
Chris - Is it normal for the kidneys to be encased in this much fat?
Alison - Yes. There always encased in fat and thatís partly a protective process.
Chris - We can see going into the kidney is an artery - thatís how the blood gets in off of the aorta. And the vein comes out and then anything that you donít want. You want to keep the blood obviously, the urine that goes down that eureta down towards the bladder. So youíve got kidney out on one side, now youíre doing the same thing on the other side...
Alison - They have an interesting external appearance. There is a small cyst; not uncommon to get small cysts in the kidney, theyíre quite harmless if there's just one or two. We have a mixture of surface appearances; we have a fine granularity to the surface. It should be very, very smooth but it isnít and then we have this much coarser indentations or scars on the surface, so weíre seeing two slightly different things there.
The fine granularity is something you tend to see in people who have high blood pressureÖ
Chris - What about the scars that you mentioned? Thereís a very bit one - it looks like a crater on the moon actually. Whatís that?
Alison - So that is likely related to chronic infection and inflammation, and itís likely that this gentleman has had infection, probably arising from bladder infections.
Chris - Itís left that legacy of the structural damage to the kidney but thatís old, thereís no evidence of that being an active infection?
Alison - No. The only thing we have is that we have some thinning cortex, thatís the outer portion of the kidney tissue, and that thinning is a feature of the high blood pressure. The coarse scarring related to previous episodes of infection but we donít have anything else at the moment active thatís going on in those kidneys.
Chris - So not a huge number of clues there, at least, not the acute cause of death yet. Now Alison did talk though, James, about high blood pressure. Why is that a problem?
James - So, in a similar way to diabetes, the presence of high pressure blood within the system can also damage the internal lining of the arteries. And, again, this can lead to hardening of the arteries of over many years, particularly if the high blood pressure is not treated.
Chris - Why does it cause that thinning of the outer surface of the kidney that Alison mentioned there, do we know?
James - Itís due to, I think, to the same reason that we get with the heart, that the blood supply to the kidney itself is reduced chronically because the arteries supplying the kidney with blood are now down, and itís this long term reduction in adequate blood supply that leads to thinning of the cortex of the kidney.
Chris - If someone has high blood pressure, what symptoms would they have had?
James - This is one of the problems with having high blood pressure, very often it causes no symptoms at all and this the reason that GPs are very keen always to measure oneís blood pressure when we go to the surgery. By the time it causes things like heart attacks and strokes and kidney problems, the high blood pressure may have been there for 20 or 30 years.
Chris - And what can someone do to control their blood pressure?
James - The best thing to do is to avoid things like smoking, to take regular exercise, try and eat a healthy diet. So, not so much red meat, plenty of fish, plenty of vegetables and fruit, and to get your blood pressure checked every year or so once you get to the age of 40. If lifestyle measures donít work, then the next step would be drug medications.
Chris - And Helen - we spotted that there was this damage to the surface of the kidney. Alison speculated that this could have been because, the gentleman being diabetic, was prone to infections and, possibly, kidney infections. Would you go along with that?
Helen - People with diabetes are prone to some types of infections and one particular site where people may get more infections in their feet, partly due to the damage to their nerves. People will injure their feet and not know, the blood supply can be reduced and so the cells that fight infection are slower to get there and also, if the sugar levels are high, it may be there's a better sort of culture medium for the bugs to grow in. So, certainly, we see increased levels of infections in feet and ulcers. As for the kidneys, Iím not sure we see a awful lot of extra kidney infections in people with diabetes but, I suppose you could speculate that, if the sugar levels were high and there was some injury there, there may be some focus for an infection to develop.