Chris - Consultant pathologist Alison Cluroe took me through a case that she dealt with recently. Now the descriptions in this piece are quite graphic so if you are at all queasy or if you think you might be distressed by hearing how a post-mortem is carried out then you might want to turn off your radio for about ten minutes, which is roughly how long this took.
Alison - My name is Dr Alison Cluroe and Iím a pathologist. This morning Iím going to take you through a post mortem examination on a 72 year old lady who died at home. She had a history of high blood pressure, gout and indigestion. Of late she had complained of an abdominal distension. She went to see her GP but was very reluctant to go to hospital. The GP had arranged for her to undergo some tests and those were going to happen over the course of the next few days when unfortunately she died unexpectedly and suddenly at home.
Chris - Presumably because we donít know why she died, the GP couldnít say, therefore it comes to you to try and work out what was going on with this lady and why she unfortunately died.
Alison - Yes, because the GP cannot issue a death certificate the case becomes a coronial case, referred to the coroner. He then looks at all the information and makes a decision as to whether we proceed to a post mortem examination to establish as to whether this is a natural death.
Chris - Looking at this lady what jumps out at you in your external examination. What do you think is going on here?
Alison - In essence she has a massively distended abdomen which does raise questions that some abdominal catastrophe has taken place. Looking at that distended abdomen I would be wondering has she got an intestinal obstruction? She certainly has evidence that she has been vomiting. That is clear from looking at the body. One would have to conclude that the likelihood that this is an obstruction. Whether it is an obstruction from something like an internal hernia, twisted bowel or tumour, we will have to wait until we do the internal examination.
Chris - The fact that she had a history of high blood pressure. Could that be an aneurism?
Alison - Yes. She does have a history of hypertension. One of the pathologies that goes hand in hand with that is an aneurism of the abdominal aorta. The aorta is a large artery running through the abdomen and on occasion in people with hypertension it can balloon out. The wall becomes paper thin, itís carrying a large amount of blood under pressure so there is a possibility that this balloon can burst with massive intra abdominal haemorrhage. So that would be another possible in the differential diagnosis.
Chris - The next step presumably is to open the body up and have a look at what is going on inside?
Alison - Indeed. At that point we undertake an evisceration which is done in combination with a mortuary technician. So now we are opening the chest and abdomen and we can see the distended abdomen very tight as the abdomen is opened. There is a large amount of blood stained fluid pouring from the opening and large loops of distended bowel packing the abdominal cavity. There is a small hernia next to the umbilicus, the belly button, where a small piece of bowel has pushed through the abdominal wall. Itís a possibility at this moment that that hernia has caused an obstruction to the bowel and is responsible for a lot of the pathology that we are seeing here.
Chris - How would that happen if that were the case?
Alison - The small piece of bowel gets trapped within the hernial sac and obstructed so no fluid or food could pass further along the bowel. As more fluid is drunk and more food is eaten the bowel distends and distends and distends. This cause the abdominal distension that we see. As Iím watching this happening and I see the technician is starting to dissect a little bit further there appears to be some sort of tumour in here. So Iím beginning to change my thought processes as we go along here.
Chris - Thereís some little patches of it on the wall of the abdomen that we can see.
Alison - Yes, we can see here on the shiny peritoneal surface the lining of the abdomen there are several nodules of white tumour that are now apparent as we fold back the abdominal wall. Itís also apparent that weíve got large masses of tumour glueing the bits of small bowel and large bowel at the back of the stomach. It looks to me in fact that this lady has got a massive intra-abdominal tumour thatís probably arising from one of the intra-abdominal organs.
Chris - Maybe bowel or maybe ovary?
Alison - Maybe bowel although with that pattern of spread I would be wondering about ovary. Commonly, bowel likes to go to the liver whereas ovary likes to go around the abdominal cavity. The pattern Iím seeing at the moment would make me think itís going to be an ovarian tumour.
Chris - I suppose if we now look through the organs that have been removed we might get some clues?
Alison - Yes, I think so. I think we should move on and have a look at the organs now. What Iím going to do is capture each of the organs individually. Starting with the spleen, itís a slightly softened spleen which suggests some underlying infection, not surprisingly with the degree of disease going on in the abdomen here in the intestinal obstruction. It doesnít appear to have any tumour in it. Moving on to have a look at the kidney I can see no evidence of tumour. There is, however evidence of surface scarring in this kidney.
Chris - Itís not smooth, is it? There are some little pock marks on the surface. What are they?
Alison - Thatís right. The pock-marked areas would suggest previous episodes of kidney infection and pyelonephritis. These leave quite coarse scars on the surface. In addition, thereís a very fine, granular scarring over the surface of the kidney which is something you see in people who have a history of hypertension: high blood pressure.
Chris - But that wouldnít have caused the present problem?
Alison - No. Those were incidental findings. If we move on to have a look at the liver Ė as I slice through the liver we can see two tiny tumour deposits which are the white, soft, fleshy tumours exactly the same as weíre seeing within the abdomen.
Chris - They stand out really prominently, donít they? The liverís a nice, brown, very homogenous, regular colour in appearance. There are these white blobs standing there as if someoneís actually pressed them on.
Alison - Thatís right. Very clear, well-defined nodules which are metastatic deposits of tumour. Thsi tumour has spread to the ladyís liver.
Chris - Would it get there though the blood supply then?
Alison - Likely to be spread by bloodstream. Tumourís spread by three methods: direct spread, through the blood stream and through the lymphatic channels in the lymph nodes. In this case this would be blood-borne spread, yes. If we move on now to have a look at the thoracic organs, the organs within the chest and start by having a look at this ladyís heart because we know she has a history of high blood pressure. That tends to make the heart enlarge. As weíre examining it here I think you can see she does, in fact, have a big heart; a very meaty looking left ventricle of the heart. This is the one that pumps the blood around the body. Itís quite evident that there is a thickening of the wall which would be compatible with the history as we know of high blood pressure. Looking at her coronary arteries these are the blood vessels that supply the heart. Often these become hardened with fatty deposits. In this case, in fact her coronary arteries are in very good condition. She has hardly any atheroma.
Chris - Yes, I wish my heart was that good. I suspect itís not but, this looks less normal here. Whatís this?
Alison - Yes, as weíre moving on now actually looking at this ladyís trachea Ė her main airway from the back of her throat. That airway is packed with vomit so she has aspirated vomit. If we now move on to look at the lungs you will see that all the tiny airways extending all the way out to the periphery of the lung are packed with this vomit. Unfortunately the actual final cause of death in this lady is her massive aspiration of gastric contents.
Chris - And that would have cause asphyxia, presumably?
Alison - Yes, essentially she would have asphyxiated and been unable to breathe as a consequence of that. We need to actually now go to the main source of the problem which will explain why she has had such a massive aspiration of vomit. We have here the gastro-intestinal system and we can see that the small bowel is massively dilated. As we move down its length thereís a huge, huge lump of tumour that completely encloses and encases the bowel and has essentially obstructed the bowel.
Chris - Does this give you any clues as to what sort of tumour this is yet, though?
Alison - Well, I think Iím still of the opinion that I would say thereís been an ovarian primary tumour. Weíve opened the bowel, weíre looking at the bowel from the inside. I canít see any tumour arising from within the lining of the bowel which is where you would expect a primary bowel cancer to come from.
Chris - I guess the answer is to actually take a look at the ovaries and see if there are signs of cancer there.
Alison - Yes. I have here in front of me the pelvic organs which includes both the ovaries, the fallopian tube and the uterus or womb. I think you can probably see that there are these craggy, white nodular deposits all over the surface of uterus and also over both the left and right ovaries. Itís quite hard to make out where the fallopian tubes are because theyíre completely encased and embedded in these two tumour masses surrounding the ovaries. I am certain that what weíre dealing with here is a primary ovarian tumour with metastasis in and throughout the abdominal cavity and ultimately spread to the liver as well.
Chris - So we started today with someone who was found collapsed at home. They died suddenly, thatís all we knew. If you could put it all together for us and tell us how youíve actually reached the conclusion you have as to what happened to this lady.
Alison - In summary this lady has essentially had a large tumour I would think growing some time in her abdominal cavity, causing abdominal distension. We have massive tumour deposits in her abdomen. These have ultimately ended up compressing and obstructing her bowel so sheís developed a bowel obstruction where the contents of the bowel can no longer pass normally through and which has caused her to begin to vomit. This vomiting has ultimately been so much that she has actually been unable to breathe and vomit at the same time. So sheís ended up breathing in a large amount of the gastrointestinal content into her lungs and that has caused her acute and sudden death.