Opening up the abdomen

17 June 2016

Interview with

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 scalpelstomach, 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 we've even moved anything around, there seems to be stuff everywhere.

Alison - Yes, I think it's probably a bit like a personal fingerprint - no-one's is probably quite the same. But you're right, it doesn't look anything like the text books.

Chris - Do you preserve the contents of what's in the intestine?

Alison - Yes. So what you're 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 that's to preserve the stomach contents should we need to analyse it. Sometimes we do in a case where we're 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 you've put over the gentleman's legs and, on top of that table, you're putting each of the things that we have removed from inside his body. And so now, this is the process where you're beginning to look at each of the organs in turn to step through them and see if there's anything in there.

Alison - That's right. So, with my scissors I'm cutting down the gullet and into the stomach. There's 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 here...

Chris - Yes. The lining is sort of pale grey colour, and in some places it's not grey, it's 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. That's not uncommon in people who are very unwell.

We're going to move to some of the other abdominal organs now and the first one I've 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 they're insulin dependent and need to have daily injections.

Chris - It's what - 15-20 cms long this one, isn't it?  And it's got a sort of bulbous end, a fist sized end, and then a tail coming of that, that's a few cms across, and you've 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 side...

Alison - We've got the two kidneys which are surrounded by a huge casing of fat. You can see, when I take this fat off you'll 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 that's partly a protective process.

Chris - We can see going into the kidney is an artery - that's how the blood gets in off of the aorta. And the vein comes out and then anything that you don't want. You want to keep the blood obviously, the urine that goes down that eureta down towards the bladder. So you've got kidney out on one side, now you're 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, they're 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 isn't and then we have this much coarser indentations or scars on the surface, so we're seeing two slightly different things there.

The fine granularity is something you tend to see in people who have high blood pressure...

Chris - What about the scars that you mentioned? There's a very bit one - it looks like a crater on the moon actually. What's that?

Alison - So that is likely related to chronic infection and inflammation, and it's likely that this gentleman has had infection, probably arising from bladder infections.

Chris - It's left that legacy of the structural damage to the kidney but that's old, there's no evidence of that being an active infection?

Alison - No. The only thing we have is that we have some thinning cortex, that's 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 don't have anything else at the moment active that's 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 - It's 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 it's 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 one's 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 don't 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, I'm 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.

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