Forensic Science International 155 (2005) 7–12 www.elsevier.com/locate/forsciint Death due to neurogenic shock following gastric rupture in an anorexia nervosa patient ¨ ttner, G. Mall I. Sinicina*, H. Pankratz, A. Bu Institute of Legal Medicine, Ludwig-Maximilians-University, Frauenlobstraße 7a, D-80337 Munich, Germany Received 26 March 2004; accepted 26 October 2004 Available online 13 December 2004 Abstract We report a case of fatal gastric rupture discovered after death, which developed due to a bulimic attack of a 19-year-old woman suffering from anorexia nervosa. An autopsy revealed an acute gastric dilatation and rupture without commonly observed ischemic damage of gastric wall structures. However, it may be difﬁcult to determine the cause of death despite the marked ﬁndings. The death as a consequence of neurogenic shock accounts for all the results of gross examination and histologic analysis. This case is the ﬁrst reported case of fatal gastric rupture of an anorectic patient discovered after death. # 2004 Elsevier Ireland Ltd. All rights reserved. Keywords: Gastric rupture; Anorexia; Binge eating; Fatal 1. Introduction Anorexia nervosa is a common psychiatric condition of adolescence in which, apart from the striking psychopathology, somatic complications are frequently observed. The disease has one of the highest death rates of any psychiatric disorder. The documented crude mortality rates of anorexia nervosa range from 3.3% in an 8-year follow-up study  to 18% in a 33-year outcome study . Causes of death reported for anorexia nervosa patients include complications of the eating disorder such as inanition, electrolyte imbalance, dehydration , suicide , and less commonly, alcoholism . There are two cases of fatal gastric rupture in anorectic patients reported by Lebriquir et al.  and Saul et al. . The young women treated by the authors died from septic shock in consequence of surgical treatment. However, acute gastric dilatation can often be observed in cases of * Corresponding author. Tel.: +49 89 51605111; fax: +49 89 51605144. E-mail address: [email protected]
(I. Sinicina). anorectic patients experiencing episodes of binge eating . Yet only a few case reports exist concerning gastric necrosis and consequent rupture following acute gastric dilatation after binge eating [6,8–11]. The patients described in the literature attended a hospital with a chief complaint of increasing severe abdominal pain. All patients were surgically treated and all but two survived. In this paper, we report on a case of a young anorectic woman who died suddenly and unexpectedly following an episode of binge eating and we review previous reports on the subject as well. 2. Case report A 19-year-old woman was found dead kneeling at the water-closet in the bathroom of her apartment. Her left arm loosely hang into the closet, her head bent forward. On external examination postmortal lividity was present on the back of the thighs, on the legs below the knees, on the face and on the forearms of the deceased (Fig. 1). Fully established postmortem rigidity was observed in all parts 0379-0738/$ – see front matter # 2004 Elsevier Ireland Ltd. All rights reserved. doi:10.1016/j.forsciint.2004.10.021 Sinicina et al. with a ﬂattened mucosa. except a slight injection of the small subserous vessels. extending from the xyphoid to the pubis. with a small amount of blood within its cavities. A single 15 cm perforation of the anterior wall of the gastric body was detected (Fig. 1. About 5600 ml of yellowish and brownish thick ﬂuid were detected in the abdominal cavity and in the stomach (Fig. 2). She had been known to suffer from anorexia nervosa for 5 years. a ﬁlling of the sulci and a discrete herniation of the cerebellar tonsils through the foramen magnum. 3). even resembling ‘‘fresh bruises’’. A faint green discoloration of the skin was noted at the right abdominal wall. of the body. that almost ﬁlled the entire abdominal cavity. / Forensic Science International 155 (2005) 7–12 Fig. The postmortem examination revealed a massively dilatated stomach. The examination of the brain showed the signs of a slight cerebral edema with a general ﬂattening of the gyri. A slight edema and strong hypostasis of the vaginal and anal entrances were present. Nevertheless. There were no signs of any injury to the thoracic or abdominal walls. The small and large bowel were both hypostatic. No petechia was observed in the palpebral conjunctiva. The heart weighed 165 g only. Photographs were taken and an autopsy was carried out. fresh intramural hemorrhages . Her weight and her height were presently 43 kg and 155 cm. Due to the nature of the case any sexual interference could not be excluded. The histological examination showed autolysis of the gastric mucosa. The cornea was slightly clouded and the pupils showed a circular shape. The position of the deceased. The urinary bladder was empty. The abdomen was remarkably distended. The lungs showed a dry cut surface. Fresh hemorrhages surrounded the margin of the rupture. the left lung 155 g. The gross examination of the serous surface showed no ﬁbrin formation due to inﬂammation. The right lung weighed 180 g. The external anterior surface of the stomach was of a patchy reddish colour. Signs of hematemesis or vomit around the body or in the closet could not be found. The deceased had last been seen the previous evening. The gastric wall was extremely thin. respectively.8 I. Fig. / Forensic Science International 155 (2005) 7–12 9 Fig. Gastric content recovered from the stomach and the abdominal cavitiy.I. Gastric wall with fresh rupture. 3. . 2. Sinicina et al. / Forensic Science International 155 (2005) 7–12 Fig. During binge eating attacks the stomach may harbour up to 12 l . Areas with atrophic epicardial adipose tissue were detected. Gastric emptying and oesophageal motility are impaired in patients with bulimic episodes. Other symptoms such as an absent femoral pulses due to markedly increased intraabdominal pressure can be present. Â100). 4. Gastric wall with thickened gastric submucosa and freshly ruptured blood vessels (EvG.Death was attributed to neurogenic shock in consequence of a gastric rupture. In some small areas of the lungs the alveoli were contained some granulocytes and ﬁbrin. Some fresh ruptures of intramural blood vessels were observed as well. Sinicina et al. Occasionally strong granulocytic inﬁltration of the bronchial walls was seen. were found at the margins of the rupture without necrotic areas or inﬂammatory inﬁltration.  Present case Year 1968 1978 1981 1987 1990 1996 2000 2003 Gastric wall Necrosis Necrosis Necrosis Necrosis Necrosis Necrosis Necrosis No Surgical treatment Yes Yes Yes Yes Yes Yes Yes No Outcome Recovery Death (septic shock) Death (septic shock) Recovery Recovery Recovery Recovery Death (neurogenic shock) . A marked ﬁbrous thickening of the entire gastric submucosa was present (Fig. the collections of lipofuscin granules were present at the poles of the nuclei. Discussion Anorexia nervosa is an eating disorder that may be accompanied by episodes of binge eating.  Petrin et al. Toxicologic analysis failed to detect any drugs. The food intake during a bulimic attack can be enormous. alcohol or unusual substances. Vomiting may cause an acute increase in intragastric Table 1 Reported cases of gastric rupture due to bulimic attack in anorexia nervosa Number 1 2 3 4 5 6 7 8 Author Evans  Lebriquir et al. The patients who developed an acute gastric dilatation have a history of progressive abdominal pain. 4). Under physiologic conditions the stomach contains up to 3 l ﬂuid and/or food.10 I. Thus. a bulimic binge can become life-threatening if the stomach does not empty spontaneously.  Saul et al. The myocardial cells were atrophic and narrow.  Nakao et al.  Willeke et al. 3.  Abdu et al.  C. Apart from the acute gastric rupture. At the autopsy no convincing morphological explanation of the cause of his death could be found: no signs of hemorrhage or peritonitis were present. Trott. Nissen. gastric ruptures are usually located in the lesser curvature of stomach. Evans. forensic pathologists should be aware of such a potential condition. Transient sinus arrest often follows. . Sem. Petzold. New York.H. E. Rather. C. Lebriquir. E. Herzog. Tacchetti. F.  C. Although fatal neurogenic shock is extremely rare and very difﬁcult to prove. Acute gastric dilatation and anorexia nervosa. Chir. Norring.  G. 37 (1994) 55–58. Outcome. cardiac atrophy and focal pneumonia were found in our case. Springer.  D.G. the autopsy revealed marked signs of sudden death but no hemorrhage. Culver. Fiehn. D. In our case. Med. Acute distension followed by gastric rupture after an episode of bulimia. Characteristically. the deceased was used to repeatedly occurring gastric distension following binge eating.I. Scand. Patton. W. / Forensic Science International 155 (2005) 7–12 11 pressure resulting in rupture.A. 108 (1990) 525–526. Dintsman. Bernardi.15]. G.  W. In the English literature. previously healthy man due to the rupture of the stomach was reported by Ishikawa et al. Mortality in eating disorders. Altogether these reactions result in neurogenic shock. Acta Psychiatr. it is a paradoxical interruption of sympathetic excitation associated with parasympathetic excitation. M.  Y. Br. Rogez. 9 (1973) 1574–1577. References  G. T. This activation induces generalized extensive peripheral vasodilatation and a decrease in blood pressure along with bradycardia. . Elliger. 54 (1978) 1175–1176. an extreme and relatively rare complication of anorexia. Preciso. 87 (1993) 437–444. According to Ishikawa et al. Surg. Acute dilatation and spontaneous rupture of the stomach.E. indicating that the gastric rupture was fatal within an extremely short period of time. Abdu.P.  R. Rupture may be caused by gastric wall necrosis secondary to ischemia. the resulting reduction in blood pressure is severe. All case reports in Table 1. G. Gastric rupture followed by release of approximately 5. Report of fatal outcome in patient with anorexia nervosa. 127 (1990) 213–215. P.C. Recently. S. The cause of death was determined as death from shock caused by gastric rupture due to overeating. In our case. 1 with gastric rupture. Herzog. Droy. Dekker. A case report. Moirot.C. Similar mechanisms are discussed in lethal outcomes following striking on epigastrium [14. sudden and unexpected death of a 49-year-old. A known laxative abuse and repeatedly induced vomiting suggest at least temporary hypovolaemia. Sinicina et al.A.M. documented gastric infarction and rupture and suggested that the obstruction of the venous outﬂow causes infarction and perforation in acute gastric dilatation. J. 27 (1997) 269–279. Leroy. which causes profound vasodilatation and bradycardia. Med. Hop. no acute ischemic damage of the mucosa was established by means of histological examination. Deter.  S. J. Medical ﬁndings and predictors of long-term physical outcome in anorexia nervosa: a prospective 12-year follow-up study. W. J. Garritano. Surg. Spontaneous rupture of the stomach. S. 18 (1988) 947–951. 122 (1987) 830–832. Acute abdomen in anorexia nervosa. Deter. and the heart rate decreases. the ﬁrst death from gastric perforation in a temporarily well-nourished woman suffering from anorexia was reported by Saul et al. Med. Theander. In all described cases the patients were admitted to the hospital with the symptoms of an acute abdomen. Mion. Med. An organic stenosis was found neither in cardia nor in pylorus.  M. All but two reported patients recovered after a surgical treatment. Gut 22 (1981) 978– 983. Arch. The defect is not a failure of the heart to respond effectively to neurogenic or humoral excitatory drive. The combination of all the above factors with neurogenic shock likely inﬂuenced the fatal outcome of gastric rupture in our case. . J. J. Psychol. no ﬁbrin or abscess formation nor peritoneal adhesions. But what type of shock should be considered? Extreme gastric distension alone may cause a vaso-vagal syncope. J.  S. plasma norepinephrine levels do not increase. A. sympathetic activity is inhibited. Wolloch. in: W. 55 (1968) 940–942. the young woman had obviously tried to induce vomiting. Fortschr. Saul.6 l of stomach content into the peritoneal cavity leads to the widespread peritoneal irritation and consequently to the strong vagal activation. Petrin. relapse and mortality across six years in patients with clinical eating disorders. Isr. O. In our case. Kerscher. According to Wolloch and Dinstman  gastric dilatation causes direct mucosal necrosis. G. H. Sohlberg. pp. recovery. Can. 1992. a distributive shock due to imbalance of sympathetic and parasympathetic regulation of vascular smooth muscles and heart rate.E. The marked ﬁbrous thickening of gastric submucosa in our case is consistent with chronic ischemic damage of the gastric wall. We found only six cases of acute gastric dilatation and rupture (including our case) due to bulimic binging in anorexia nervosa patients (Table 1). Disseminated intravascular coagulation complicating gastric perforation in a bulimic woman. Gallo. H. when the wall tension exceeds the venous pressure. Sci. M. . Felix.  G. 217–227. Psychol.S. The Course of Eating Disorders. Chronicity in anorexia nervosa: results from the Swedish long-term study. J. Vandereyken (Eds. the rupture was located in the anterior wall of the gastric body.S. Watson. Thus. Surg.S. Apropos of 2 cases. Acute gastric necrosis in anorexia nervosa and bulimia. Two case reports. In our case. Roseborough.). Acute gastric dilatation with infarction and perforation. Gastric perforation caused by a bulimic attack in an anorexia nervosa patient: report of a case. Y. Ogata. Dtsch. Ago. V. Ago.  Y.  T. H. Riedl. K. Hoffmann. Wochenschr. Nippon Hoigaku Zasshi 46 (1992) 152–158. Inagaki. O. Furuya. Kita. M. Nakao. Iwagaki. S. S. Kanagawa. N.12 I. K. Ishikawa. H. T. Med. J. Leg Med. T. Neurogenic shock caused by striking on epigastrium. 5 (2003) 60–64. Sinicina et al. S. Tanaka. Shintaku. Tsuganezawa.  M. von Herbay. A case of death due to neurogenic shock. 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