Partial bowel obstruction in a 2-month-old child. A delayed diagnosis of anal abuse

We present the case of an anal sexual abuse involving a 2-month-old boy, who was admitted to the Pediatric Surgery Unit of the University of Padua for low bowel obstruction. The infant had been already hospitalized for 3 days in a peripheral hospital and treated with daily rectal wash-outs for a fecaloma. Only after a careful interpretation of the plain abdominal radiograph, along with the performance of a rectoscopy and a laparotomy, a vegetable foreign body (about 3 cm in diameter and 7 cm in length) was discovered in the sigma. The morphology and dimensions of the foreign body, as well as its location, left no doubt about the etiology of the partial bowel obstruction, proving that it was clearly related to an anal sexual abuse.     

Transmesenteric hernia due to double-loop formation in the small intestine: a fatal case involving a toddler

We report a unique case of transmesenteric hernia resulting in death, which went undiagnosed during a recent hospital visit. The victim was a 2.5-year-old girl who - with the exception of chronic constipation - had no medical history. One night she complained of abdominal pains and was taken to a pediatric hospital where doctors performed an abdominal X-ray and echography. No significant findings suggesting bowel obstruction (e.g. air-fluid levels or dilation of the bowel) were obtained on examinations and bloody feces were not observed in this particular episode. As her abdominal pain gradually attenuated, the doctor allowed her to return home. A few hours later, she lost consciousness and expired despite resuscitation efforts attempted at an emergency hospital. A subsequent autopsy revealed that the small bowel had herniated through a defect in the mesentery resulting in two consecutive and inversely forming loops, in which each loop protruded on either side of the mesentery. This rare morphological anatomy seems to have progressed in a two-step process. The girl's mild abdominal pain was likely induced by herniation and formation of the first intestinal loop, followed by severe shock occurring when the subsequent intestinal segment invaginated into the same defect forming the second loop on the opposite side of the mesentery. This case illustrates the difficulty of diagnosing transmesenteric hernia due to the presentation of unspecific symptoms; especially in infants and toddlers. Furthermore, this report demonstrates the value of a complete autopsy in cases of sudden and unexpected deaths involving children.     

Small bowel perforation as a complication of microsurgical lumbar diskectomy. A case report and brief review of the literature

Ventral perforation is a rare complication of lumbar diskectomy. Injury to retroperitoneal vessels is the most common serious complication to such perforation. Ventral perforation with damage to the bowel is rarely reported. The authors present the first case report of injury to the small bowel during a microsurgical lumbar diskectomy. The case illustrates the importance of awareness of bowel injury as a possible complication of diskectomy. Possible pre- and postoperative considerations are also discussed. A brief review of the literature on bowel injuries after this common surgical procedure is also given.     

Sudden death from hyponatremia and hypokalemia in a woman with Gardner syndrome.

The authors present the case of a 39-year-old woman with Gardner syndrome who died from marked hyponatremia and hypokalemia. Gardner syndrome is a rare variant of the familial adenomatous polyposis syndrome in which the affected individual develops thousands of polyps within the gastrointestinal tract, with a 100% risk of eventual malignant change. Individuals with Gardner syndrome also develop a variety of extra gastrointestinal abnormalities. In the case presented, a woman with a clinical history of Gardner syndrome who had previously undergone a total colectomy with ileorectal anastomosis presented to the hospital with a recent history of sore throat, fever, diarrhea, and abdominal pain. The symptoms were considered clinically to be due to a viral gastroenteritis. She was admitted to the hospital, where she had episodes of collapse believed to be vasovagal in origin. She suffered a cardiorespiratory arrest and died 24 hours after admission. After her death, electrolyte estimation performed on blood taken shortly before death revealed severe hyponatremia and hypokalemia. Postmortem examination showed the gastric mucosa to be virtually covered by innumerable adenomatous and hyperplastic polyps. Fewer polyps were seen within the small bowel. There was no evidence of malignancy. The features were consistent with Gardner syndrome. Hyponatremia and hypokalemia have been described in patients with villous adenomas and in familial adenomatous polyposis syndromes associated with numerous colonic polyps. The cause of death in this case was considered to be hyponatremia and hypokalemia associated with florid gastric polyps in a woman with Gardner syndrome. Viral gastroenteritis contributed to the death by causing further electrolyte depletion. To the best of the authors' knowledge, death in Gardner syndrome has not been described as attributable to such metabolic disturbance, in particular in those who have only gastric, small bowel, and rectal polyps remaining after total colectomy.     

An unusual foreign body in the distal small intestine: case report

A case of a deceased 77-year-old woman presenting to the coroner for postmortem examination scribed. A plastic tie used to seal loaves of sliced bread and other plastic-wrapped food stuffs was found clamped by its "teeth" to a length of small bowel proximal to the cecum, resulting in localized mucosal ulceration, thickening, and edema of the bowel wall. There was also infarcted small bowel due to aortic atherosclerosis, which was submitted as the cause of death. The presence of the bread tie probably did not significantly contribute to death but was as an unusual finding at postmortem examination and has not been previously described.     

Neurosurgical vascular complications associated with aneurysm clips evaluated by postmortem angiography.

Neurosurgical vascular complications were evaluated by postmortem angiography in a consecutive prospective series of 63 patients in Helsinki who suffered a fatal outcome following neurosurgery for ruptured intracranial aneurysm. Operative vascular complications were revealed in 28 (44%) of the cases. Massive intraoperative bleeding resulting from rupture of the aneurysm or adjacent major artery during dissection or clip application complicated the operation in 16 (25%) patients. Clip-induced obstruction of cerebral arteries was detected by angiography in seven cases (11%). In six of the patients an adjacent cerebral vessel was accidentally clipped. In one case a kinking of the clip had caused obstruction of the right anterior cerebellar artery with resulting frontal infarct. A combination of rupture of the internal carotid artery and accidental ligation of the left posterior cerebellar artery occurring simultaneously during the clipping of a ruptured basilar aneurysm was detected in one patient (2%). Other types of complication were revealed in four cases (6%): detachment of clip with re-bleeding; clipping of an uninvolved aneurysm instead of the ruptured one; displacement of the clip beneath the ruptured aneurysm. Operations on ruptured basilar artery aneurysm were significantly (P less than 0.01) more prone to complications. The results indicate that operative vascular complications play a significant role in the mortality of aneurysm patients. Post-mortem angiographic technique with contrast medium that vulcanizes at room temperature is particularly suitable for demonstration of the haemodynamic significance of clip-induced cerebrovascular accidental occlusions, and is the only method at autopsy to reveal an occlusion caused by a kinking of a properly placed aneurysm clip.     

Deliberate ingestion of foreign bodies as a form of self-harm among inpatients within forensic mental health and intellectual disability services

Deliberate foreign body ingestion is a significant issue in prison and psychiatric settings. It is associated with serious physical complications, including bowel obstruction, perforation and haemorrhage. Episodes of deliberate foreign body ingestion were identified retrospectively from 5417 incident records from two inpatient forensic services (one mental health and one intellectual disability) over a one year timeframe, using related search terms. Rates were compared according to gender, diagnosis and level of security. Incidents of deliberate foreign body ingestion were found to occur on average every 2.7 days across the study population, with 133 incidents recorded over a one year period, accounted for by 27 patients. Women and patients in lower levels of security were significantly more likely to engage in deliberate foreign body ingestion. Staff responses to this behaviour were highly variable. Deliberate foreign body ingestion occurs frequently within inpatient forensic services, and can have significantly detrimental physical implications for affected patients. Further research should investigate the psychiatric and intellectual disability profile of such individuals in further detail, as well as exploring patient narratives; both of which will help inform development of treatment strategies.     

Beyond cognition: the role of disordered affective states in impairing competence to consent to treatment.

Most of the criteria for competence in current use emphasize cognitive rather than affective dimensions. Our clinical experience indicates that affective disorders may impair competence in a detectable and identifiable way. In particular, patients with major affective disorders can retain the cognitive capacity to understand the risks and benefits of a medication, yet fail to appreciate its benefits. A case study of a pathologic grief reaction is introduced to illustrate how cognitive and affective impairments may coexist and require separate remedial strategies for restoration. Further empirical work on the role of affective disorder in impairing competence is warranted and planned.     

Sudden unexpected death resulting from previously nonsymptomatic subependymoma

A 34-year-old, previously healthy man died suddenly and unexpectedly. The autopsy showed brain and pulmonary edema, numerous small meningeal meningiomas, bilateral and symmetrical juxtaventricular meningiomas, and a well-demarcated gray tan tumor in the medulla oblongata and upper cervical spinal cord. The latter tumor was a subependymoma with features of ependymoma in places. The authors describe and discuss the characteristics of this rare central nervous system tumor, its histogenesis, and its coexistence with other intracranial tumors. The possible mechanisms of death in the present case include compression of vital centers and acute obstruction of the cerebrospinal fluid flow.     

Littre hernia--a rare cause of unexpected death in the elderly

A rare case of sudden and unexpected death is reported in an 87-year-old woman who was found dead at her home. At autopsy, the most striking finding was of a right-sided direct inguinal hernia containing a 20 mm infarcted Meckel diverticulum, with proximal small intestinal obstruction. Significant stenosing atherosclerosis was present in all three major epicardial coronary arteries, but with no histological evidence of acute or chronic ischemic myocardial damage. Death was attributed to small intestinal obstruction due to direct inguinal herniation (and infarction) of a Meckel diverticulum (a Littre hernia), complicating ischemic heart disease. Although Littre hernias are not a reported cause of sudden death in the elderly, congenital gastrointestinal anomalies may rarely play a significant role in terminal episodes well beyond childhood years. The autopsy assessment of sudden death at any age involves detailed examination of the entire length of the intestinal tract.     

Study of unusual phenomenon of contact firing on gelatine block using .38 Special revolver--forensic importance

Gunshot wounds in suicide cases are self-inflicted wounds. Self-inflicted wounds in suicide cases are usually caused by contact firing and are of great forensic significance. Evaluation of contact wound may be associated with difficulties if the bore gets obstruction prior to firing. This paper investigates the phenomenon and interprets the results of test firing conducted on 20% gelatine block at 10 degrees C, using .38 Special revolver with obstruction of a bullet in the bore. Test firings were conducted in three different muzzle-target contact conditions keeping the muzzle pressed against the gel block in each case. The physical evidence and the wound ballistic parameter namely bullet track, remaining velocity of the bullets and volume of permanent cavity have been studied. When compared with the results of contact firing conducted with the same firearm without having any bore obstruction under similar conditions, it has been found that the physical evidence and the wound ballistic parameters would be helpful for interpretation of such unusual incidents for forensic inference.     

Clinical and demographic characteristics of elderly offenders at a maximum-security forensic hospital

The purpose of the study was to determine the clinical and demographic characteristics of the male elderly offenders admitted to a maximum-security forensic hospital. Charts of male elderly patients were reviewed to obtain clinical and demographic data. Seventy-seven percent of geriatric felons were involved in violent crime, 41% of which had psychotic symptoms. Forty-five percent of offenders with a history of head trauma/neurologic disorder were charged with violent offenses. Fifty-nine percent had previous psychiatric hospitalization. Most elderly male offenders involved in violent crimes had primary psychotic and mood disorders, cognitive impairment, and a history of head trauma/neurologic disorder. The small number of subjects precludes clear conclusions and needs further study.     

Return of the killer fish: accidental choking death on a bluegill (Lepomis macrochirus)

An unusual case of choking is presented. In this case, a 45-year-old man, while fishing and drinking with friends, attempted to swallow a whole fish. He subsequently asphyxiated as a result of upper airway obstruction.     

Fatal Clostridium perfringens Septicemia After Colonoscopic Polypectomy,Without Bowel Perforation

Since its introduction, colonoscopy has played an important role as a diagnostic, therapeutic, and screening tool. In general, colonoscopy is regarded as a safe procedure, but complications may occur. The most dreaded of these complications is colonic perforation. Bacteremia postprocedure may occur, and although it is not uncommon, it rarely results in clinically significant complications. Patients with IBD (inflammatory bowel disease) are a high‐risk population for bacteremia, which may leads to bowel wall overstepping by the bacteria. With regard to that, we report a fatal case of gas gangrene complicating colonoscopy polypectomy without bowel perforation in a healthy adult. To the best of our knowledge, only two other cases of retroperitoneal gas gangrene associated with colonoscopy polypectomy without bowel perforation have been described in international literature, but none of which was completed by a molecular biology analysis.     

The seromuscular tear and other intestinal lesions in the seatbelt syndrome: a clinical and pathologic study of 29 cases

The authors describe the clinical and pathologic findings in 29 patients with injuries from motor vehicle accidents. The seromuscular tear (SMT), the hallmark intestinal injury of the seatbelt syndrome, is an unambiguous lesion similar in all segments of bowel and is caused by a tear that separates the inner muscularis from the submucosa. It is characterized by (1) a wedge that strips the submucosa from the inner circular muscle; (2) a bending retraction of the torn muscularis toward the uninvolved bowel wall; (3) mucosal-submucosal fold effacement, causing the mucosa-submucosa bridge spanning the tear to become paper thin; and (4) the vulnerability of this bridge to ischemia that in 35% of the tears studied culminated in incipient or frank perforations and/or gangrene. Large SMTs, particularly the circumferential degloving type, are most prone to develop these complications. These findings militate against the idea that the SMT is a trivial lesion. The SMT occurred in 90% of patients in this report and accounted for 65% of all intestinal lesions. Seventy-three percent of the tears developed in the colon, and one third of all SMTs occurred in the sigmoid colon. Two thirds of all intestinal and mesenteric injuries clustered in three sites: the ileocecal region, the sigmoid colon, and the jejunum. Perforations were the principal lesion in the jejunum and SMTs at the other two locations. Ninety percent of patients experienced two or more intestinal lesions. This suggests the simultaneous action of different traumatic mechanisms on the bowel and its mesenteries in seatbelted persons who are in motor vehicle accidents.     

A fatal elephant attack

A rare case of an elephant attack is presented. A 44-year-old man working as an elephant keeper was attacked by a cow elephant when he tripped over a foot chain while the animal was being medically treated. The man fell down and was consequently repeatedly attacked with elephant tusks. The man sustained multiple stab injuries to both groin regions, a penetrating injury to the abdominal wall with traumatic prolapse of the loops of the small bowel, multiple defects of the mesentery, and incomplete laceration of the abdominal aorta with massive bleeding into the abdominal cavity. In addition to the penetrating injuries, the man sustained multiple rib fractures with contusion of both lungs and laceration of the right lobe of the liver, and comminuted fractures of the pelvic arch and left femoral body. The man died shortly after he had been received at the hospital. The cause of death was attributed to traumatic shock.     

Meckel's diverticulum and intestinal obstruction--report of a fatal case

Meckel's diverticulum is an uncommon cause of intestinal obstruction in adult life. Rarely Meckel's diverticulum is complicated by a mesodiverticular band, which is believed to be a remnant of a vitelline artery. When this abnormality occurs it is associated with high mortality. We present a case of a 48-year-old man with increasing abdominal pain and vomiting for 3 days. Meckel's diverticulum was not taken into diagnostic consideration, and the man died. Autopsy revealed a Meckel's diverticulum with a mesodiverticular band and intestinal obstruction. Histological examination of cross sections of the mesodiverticular band showed the presence of an artery. Because of the high mortality of this rare anatomic anomaly in adults, we find the case of interest.     

Unexpected death due to intestinal obstruction by a duplication cyst in an infant

An 11-month-old female infant died at home after being diagnosed as having gastroenteritis. Autopsy examination revealed a distended distal ileum filled with a large amount of watery contents, and a 3 cm x 3 cm x 4 cm cyst at the ileocecal part of the cecum that was histologically consistent with a duplication cyst. The cause of death was determined to be acute dehydration due to intestinal obstruction caused by a duplication cyst. This case indicates that intestinal obstruction by a duplication cyst should be recognized as a cause of unexpected death in infants.