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'''Autopsy''' | [[Image:Rembrandt Harmensz. van Rijn 007.jpg|thumb|300px|An autopsy.]] | ||
'''Autopsy''' was once a mainstay of [[pathology]]. It is now in decline and uncommonly done. Fetal autopsy is dealt with in a separate article called ''[[fetal autopsy]]''. | |||
=Value of autopsy= | |||
A significant number of major findings cannot be diagnosed without histology;<ref name=pmid16324191>{{Cite journal | last1 = Roulson | first1 = J. | last2 = Benbow | first2 = EW. | last3 = Hasleton | first3 = PS. | title = Discrepancies between clinical and autopsy diagnosis and the value of post mortem histology; a meta-analysis and review. | journal = Histopathology | volume = 47 | issue = 6 | pages = 551-9 | month = Dec | year = 2005 | doi = 10.1111/j.1365-2559.2005.02243.x | PMID = 16324191 }}</ref> thus, without a biopsy or an autopsy they cannot be diagnosed. Autopsies can be regarded as a form of [[quality control]]. | |||
One large review in ''JAMA'' suggests that approximately:<ref name=pmid12783916>{{cite journal |author=Brian Gallagher, Burton EC, McDonald KM, Goldman L |title=Changes in rates of autopsy-detected diagnostic errors over time: a systematic review |journal=JAMA |volume=289 |issue=21 |pages=2849–56 |year=2003 |pmid=12783916 |doi=10.1001/jama.289.21.2849}}</ref> | |||
* 25% of autopsies reveal a finding that would have changed clinical management. | |||
* 5% of autopsies reveal a missed [[diagnosis]] that probably affected the outcome. | |||
If the '' | =Autopsy checklist= | ||
===Minimum to proceed - hospital autopsy=== | |||
*Death certificate complete. | |||
**Cause of death as per death certificate. | |||
*[[Autopsy consent]] properly done. | |||
*Patient identified. | |||
===Clinical history checklist - hospital admission=== | |||
*Admit date. | |||
*Admit diagnosis. | |||
**History of illness prior to admission? | |||
*Past medical history. | |||
**Recent hospital admissions? | |||
**Significant medical conditions. | |||
*State preceding death - especially the last 24 hours. | |||
**Level of consciousness. | |||
**Vitals. | |||
*Location at time of death and preceding 24 hours. | |||
**Ward. | |||
**Intensive care unit. | |||
**Other. | |||
*Time immediately prior to death. | |||
**Code called. | |||
**Found cold. | |||
**Other. | |||
*Date and time of death. | |||
*Clinical status prior to death. | |||
**Expected versus unexpected. | |||
=Autopsy consent= | |||
===General=== | |||
*In a hospital autopsy the ''most important'' thing is: ''proper consent''. | |||
*Generally, corner's cases/medical examiner's cases do not require a consent for autopsy; however, the retention of tissue may require consent. | |||
===Who has authority?=== | |||
*Consent should be given by the ''executor of the estate''.<ref name=olduhnconsent>URL: [http://www.docstoc.com/docs/51609856/CONSENT-FOR-AUTOPSY http://www.docstoc.com/docs/51609856/CONSENT-FOR-AUTOPSY]. Accessed on: 27 September 2010.</ref> | |||
====Hierarchy==== | |||
If the ''executor of the estate'' is not specified the hierarchy is as follows:<ref name=olduhnconsent/> | |||
#Spouse - by marriage (same sex ''or'' opposite sex) ''or'' by common-law ''or'' by together the parents of a child ''or'' by cohabitation agreement (in law). | #Spouse - by marriage (same sex ''or'' opposite sex) ''or'' by common-law ''or'' by together the parents of a child ''or'' by cohabitation agreement (in law). | ||
#If no spouse, any children 16+ years old, | #If no spouse, any children 16+ years old, | ||
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Notes: | Notes: | ||
*The power a person that is designated as ''power of attorney for health care decisions'' does not have the authority to consent for an autopsy; their power ends with death (unless they are also the '' | *Exact hierarchy may vary by jurisdiction. | ||
*In clinical medicine, it is allowable to skip down the hierarchy if ''the'' "consent giver" is not reachable, e.g. if a child of the patient is present they can consent in emergency circumstances, if the spouse is ''not'' reachable. In the context of autopsies, '''the hierarchy has to be followed strictly''', as there is no such thing as an "emergency autopsy"; it is ''not'' acceptable to ask the child of the decedent 'cause they aren't distraught like the spouse of the decedent. | *The power a person that is designated as ''power of attorney for health care decisions'' does not have the authority to consent for an autopsy; their power ends with death (unless they are also the ''executor of the estate''). | ||
*In clinical medicine, it is allowable to skip down the hierarchy if ''the'' "consent giver" is not reachable, e.g. if a child of the patient is present they can consent in emergency circumstances, if the spouse is ''not'' reachable. In the context of (non-corner's) autopsies, '''the hierarchy has to be followed strictly''', as there is no such thing as an "emergency autopsy"; it is ''not'' acceptable to ask the child of the decedent 'cause they aren't distraught like the spouse of the decedent. | |||
*In non-corner's cases/non-medical examiner's cases, a physician ''cannot'' give consent for an autopsy. | |||
===Religious objections=== | ===Religious objections=== | ||
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*It is ''not'' considered good practise to agree to restrictions that will impair a complete assessment, e.g. "stop as soon as one has the cause of death", especially in the medicolegal context (when the extent of the autopsy is at the pathologist's discretion). It is often said that... ''incomplete autopsies give incomplete answers''. | *It is ''not'' considered good practise to agree to restrictions that will impair a complete assessment, e.g. "stop as soon as one has the cause of death", especially in the medicolegal context (when the extent of the autopsy is at the pathologist's discretion). It is often said that... ''incomplete autopsies give incomplete answers''. | ||
==External exam | ==Timeliness== | ||
There are turnaround time standards from the ''College of American Pathologists'':<ref name=pmid19961247>{{Cite journal | last1 = Siebert | first1 = JR. | title = Increasing the efficiency of autopsy reporting. | journal = Arch Pathol Lab Med | volume = 133 | issue = 12 | pages = 1932-7 | month = Dec | year = 2009 | doi = 10.1043/1543-2165-133.12.1932 | PMID = 19961247 }}</ref> | |||
{| class="wikitable sortable" | |||
! Deliverable | |||
! Time | |||
! Comment | |||
|- | |||
| Provisional report | |||
| 2 working days | |||
| gross findings & history | |||
|- | |||
| "Most" final reports | |||
| 30 days | |||
| | |||
|- | |||
| All final reports | |||
| 60 days | |||
| | |||
|- | |||
|} | |||
=External exam= | |||
===General=== | ===General=== | ||
*Very important in the forensic context. | *Very important in the forensic context. | ||
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Body should be examined for ''defensive-type wounds'': | Body should be examined for ''defensive-type wounds'': | ||
*Between the | *Between the fingers - especially thumb and pointing finger. | ||
*Dorsal aspect of the hand. | *Dorsal aspect of the hand. | ||
*Forearm. | *Forearm. | ||
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*External exam findings are found in the ''[[forensic pathology]]'' article. | *External exam findings are found in the ''[[forensic pathology]]'' article. | ||
=Internal exam= | |||
===General=== | ===General=== | ||
*This is usually where the money is in hospital autopsies. | *This is usually where the money is in hospital autopsies. | ||
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===Before the first incision=== | ===Before the first incision=== | ||
If there is suspicion of pneumothorax - one the the three following can be done:<ref name=Ref_HospAuto120-1>{{Ref HospAuto|120-1}}</ref> | If there is suspicion of [[pneumothorax]] - one the the three following can be done:<ref name=Ref_HospAuto120-1>{{Ref HospAuto|120-1}}</ref> | ||
#Create a "pleural window" (between ribs by removing soft tissue... without entering the pleural cavity). | #Create a "pleural window" (between ribs by removing soft tissue... without entering the pleural cavity). | ||
#Open chest underwater and watch for air bubbles. | #Open chest underwater and watch for air bubbles. | ||
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*If there are neck abnormalities or suspicion of pressure on the neck, it is prudent to remove the cranial contents and thoracic contents ''before'' doing the neck dissection.<ref name=HospAuto118>{{Ref HospAuto|118}}</ref> | *If there are neck abnormalities or suspicion of pressure on the neck, it is prudent to remove the cranial contents and thoracic contents ''before'' doing the neck dissection.<ref name=HospAuto118>{{Ref HospAuto|118}}</ref> | ||
**If the above does ''not'' apply, i.e. there is no neck injury/suspected neck injury, the tongue & neck can be taken together with the thorax pluck or organ pluck. | **If the above does ''not'' apply, i.e. there is no neck injury/suspected neck injury, the [[tongue]] & neck can be taken together with the thorax pluck or organ pluck. | ||
===Incisions=== | ===Incisions=== | ||
*Y-shaped incision (standard): | *Y-shaped incision (standard): | ||
**Superior "points" of the Y ~ at the deltoid muscle. | **Superior "points" of the Y ~ at the deltoid muscle. | ||
**" | **"Confluence of lines" in the Y ~ inferior to the suprasternal notch. | ||
*Neck dissection incisions: | *Neck dissection incisions: | ||
**Deltoid to mastoid process. | **Deltoid to mastoid process. | ||
==== | ====Chest plate==== | ||
*Removed by cutting the ribs - usu. at the rib ends. | |||
*Ribs should be examined for fractures. | |||
*Usually of no interest. | *Usually of no interest. | ||
* | |||
Notes: | |||
*The sternum may have cleft or foramen - as an anatomical variant.<ref name=pmid10803333>{{cite journal |author=Fokin AA |title=Cleft sternum and sternal foramen |journal=Chest Surg. Clin. N. Am. |volume=10 |issue=2 |pages=261–76 |year=2000 |month=May |pmid=10803333 |doi= |url=}}</ref> | |||
*If the decedent has a history of a [[CABG]] removal of the chest plate should be done with care to preserve the grafts. | |||
===Blood clots - ''pre- and post-mortem''=== | ===Blood clots - ''pre- and post-mortem''=== | ||
{| class="wikitable" | {| class="wikitable sortable" | ||
! Feature/time | |||
! Pre-mortem | |||
! Post-mortem | |||
|- | |- | ||
|Shininess | |Shininess | ||
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|Colour | |Colour | ||
| grey; may have zebraic <br>appearance (lines of Zahn) - <br>red alt. with grey/yellow | | grey; may have zebraic <br>appearance (lines of Zahn) - <br>red alt. with grey/yellow | ||
| dark purple ''or''<br> bilayered red | | dark purple ''or''<br> bilayered yellow/red | ||
|- | |- | ||
|Pressurized | |Pressurized | ||
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| [http://eurheartj.oxfordjournals.org/content/early/2010/01/12/eurheartj.ehp557/F3.expansion.html thrombus (oxfordjournals.org)], <br>[http://pathhsw5m54.ucsf.edu/cts/unknown16/thrombi.html thrombi (ucsf.edu)] | | [http://eurheartj.oxfordjournals.org/content/early/2010/01/12/eurheartj.ehp557/F3.expansion.html thrombus (oxfordjournals.org)], <br>[http://pathhsw5m54.ucsf.edu/cts/unknown16/thrombi.html thrombi (ucsf.edu)] | ||
|} | |} | ||
Notes: | |||
*Post-mortem thrombi: one (superior) yellow portion (called "chicken fat") and one (dependent) red portion (RBCs); components layer due to gravity. | |||
===Retrieval of the (organ) "pluck"=== | ===Retrieval of the (organ) "pluck"=== | ||
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==Neck organ pluck== | ==Neck organ pluck== | ||
===Non-suspicious cases=== | |||
#Trim tissue posterior to horns of the thyroid. | #Trim tissue posterior to horns of the thyroid. | ||
#Cut between thyroid horns & hyoid. | #Cut between thyroid horns & hyoid. | ||
#Cut off base of tongue. | #Cut off base of tongue. | ||
===Suspicious cases=== | |||
*In Canada, it is convention to do ''layered neck dissection''. | |||
**The strap muscles of the neck are lifted of in layers to look for injuries (mostly contusions). | |||
**Strap muscle hematomas may arise in a number of contexts, e.g. they are reported in drowning.<ref>{{Cite journal | last1 = Püschel | first1 = K. | last2 = Schulz | first2 = F. | last3 = Darrmann | first3 = I. | last4 = Tsokos | first4 = M. | title = Macromorphology and histology of intramuscular hemorrhages in cases of drowning. | journal = Int J Legal Med | volume = 112 | issue = 2 | pages = 101-6 | month = | year = 1999 | doi = | PMID = 10048667 }}</ref> | |||
====Hyoid bone==== | ====Hyoid bone==== | ||
*Important in forensic pathology. | *Important in forensic pathology. | ||
*Fracture is seen in manual strangulation. | *Fracture is seen in manual [[strangulation]]. | ||
*May appear fractured if triticeous cartilage (or triticeal cartilage) is present;<ref name=pmid15075682>{{cite journal |author=Di Nunno N, Lombardo S, Costantinides F, Di Nunno C |title=Anomalies and alterations of the hyoid-larynx complex in forensic radiographic studies |journal=Am J Forensic Med Pathol |volume=25 |issue=1 |pages=14–9 |year=2004 |month=March |pmid=15075682 |doi= |url=}}</ref><ref>URL: [http://faculty.ksu.edu.sa/Prof.Hamam/curses/Jurnals%20Club/225-Triticeous%20cartilage.pdf http://faculty.ksu.edu.sa/Prof.Hamam/curses/Jurnals%20Club/225-Triticeous%20cartilage.pdf]. Accessed on: 10 September 2010.</ref> triticeous cartilage may be confused with a fragment of hyoid bone. | *May appear fractured if triticeous cartilage (or triticeal cartilage) is present;<ref name=pmid15075682>{{cite journal |author=Di Nunno N, Lombardo S, Costantinides F, Di Nunno C |title=Anomalies and alterations of the hyoid-larynx complex in forensic radiographic studies |journal=Am J Forensic Med Pathol |volume=25 |issue=1 |pages=14–9 |year=2004 |month=March |pmid=15075682 |doi= |url=}}</ref><ref>URL: [http://faculty.ksu.edu.sa/Prof.Hamam/curses/Jurnals%20Club/225-Triticeous%20cartilage.pdf http://faculty.ksu.edu.sa/Prof.Hamam/curses/Jurnals%20Club/225-Triticeous%20cartilage.pdf]. Accessed on: 10 September 2010.</ref> triticeous cartilage may be confused with a fragment of hyoid bone. | ||
**''Triticeous'' is pronounced ''tri-tish´us''.<ref>URL: [http://medical-dictionary.thefreedictionary.com/triticeous http://medical-dictionary.thefreedictionary.com/triticeous]. Accessed on: 15 September 2010.</ref> | **''Triticeous'' is pronounced ''tri-tish´us''.<ref>URL: [http://medical-dictionary.thefreedictionary.com/triticeous http://medical-dictionary.thefreedictionary.com/triticeous]. Accessed on: 15 September 2010.</ref> | ||
====Larynx injury==== | |||
These are worked-up in great detail in Germany.<ref name=Gazov>Evgenij Gazov. LMU Rechtsmedizin. 8 July 2011. Possibly described more here: [http://www.reference-global.com/doi/abs/10.1515/9783899496079.1027 http://www.reference-global.com/doi/abs/10.1515/9783899496079.1027]</ref> In Canada, the examination, by comparison, is superficial. A detailed examination of the larynx may offer significant information in [[asphyxial deaths]]. | |||
Process: | |||
*Pre-evaluation - if a larynx injury is suspected: | |||
**The larynx should '''not''' be opened. | |||
**Soft tissue should be removed with blunt dissection. | |||
*Evaluation (done with a stereo microscope): | |||
**Tension - splits/tears, bleeding. | |||
**Compression - surrounding tissue no splits/tears. | |||
**Partial fractures - give information about directionality. | |||
Recognized patterns: | |||
*Left horn of thyroid cartilage fracture - choking with left-handed. | |||
*Right horn of thyroid cartilage fracture - choking with right-hand. | |||
*Cricoid cartilage two fractures anteriolateral - choke hold from behind. | |||
==Dissection of thoraco-abdominal pluck== | ==Dissection of thoraco-abdominal pluck== | ||
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#*Check renal veins. | #*Check renal veins. | ||
#Separate IVC. | #Separate IVC. | ||
#Transect [[esophagus]] (~2 cm) distal to inferior margin of the cricoid cartilage. | |||
#Take down esophagus using blunt dissection (to separate from thorax). | #Take down esophagus using blunt dissection (to separate from thorax). | ||
#Separate thorax and abdomen - by dissecting through | #Separate thorax and abdomen - by dissecting through the [[pericardium]]. | ||
===Common finding(s)=== | ===Common finding(s)=== | ||
*Aorta = | *Aorta = [[atherosclerosis]]. | ||
===Things to think about=== | ===Things to think about=== | ||
*Renal arteries = atherosclerosis (old), fibromuscular dysplasia (young). | *Renal arteries = atherosclerosis (old), [[fibromuscular dysplasia]] (young). | ||
*Renal veins = [[renal cell carcinoma]]. | *Renal veins = [[renal cell carcinoma]]. | ||
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===Respiratory system=== | ===Respiratory system=== | ||
#Open trachea + bronchus (see ''Note''). | #Open [[trachea]] + bronchus (see ''Note''). | ||
#Examine proximal airway. | #Examine proximal airway. | ||
#Examine proximal pulmonary arteries. | #Examine proximal pulmonary arteries. | ||
#*May be done from intralobular fissures<ref>Ali-Ridha, HN. 8 October 2010.</ref> | #*May be done from intralobular fissures.<ref>Ali-Ridha, HN. 8 October 2010.</ref> | ||
#**The large arteries of the right lung is found deep to oblique fissure.<ref name=Ref_HospAuto156>{{Ref HospAuto|156}}</ref> | #**The large arteries of the right lung is found deep to oblique fissure.<ref name=Ref_HospAuto156>{{Ref HospAuto|156}}</ref> | ||
#Slice lungs - one lobe at a time (easier to cut). | #Slice lungs - one lobe at a time (easier to cut). | ||
#Squeeze lungs - to test | #Squeeze lungs - to test for the presence of pus and [[pulmonary edema|edema]] fluid.<ref name=Ref_HospAuto156>{{Ref HospAuto|156}}</ref> | ||
Note: | Note: | ||
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{{Main|Lung}} | {{Main|Lung}} | ||
*Plural adhesions. | *Plural adhesions. | ||
*Plural effusions. | *Plural [[effusions]]. | ||
*Edema - fluid comes-out when you squeeze 'em, "heavy" (large mass). | **Types: ''serous'' (clear), ''serosaginous'' (cloudy), ''serofibrinous'' (clotted/webbed), ''purulent'' (yellow). | ||
*Emphysematous change (usu. upper lung zone predominant) +/- black pigment (anthracosis). | *[[Pulmonary edema|Edema]] - fluid comes-out when you squeeze 'em, "heavy" (large mass). | ||
*Consolidation - best appreciated by running a finger over the cut surface of the lung with a small-to-moderate amount of pressure. | *[[emphysema|Emphysematous change]] (usu. upper lung zone predominant) +/- black pigment (anthracosis). | ||
*Consolidation - best appreciated by running a finger over the cut surface of the lung with a small-to-moderate amount of pressure; often [[pneumonia]]. | |||
*Atelectasis - depressed red areas.<ref>{{Ref AoGP|90}}</ref> | |||
==Abdominal organ pluck== | ==Abdominal organ pluck== | ||
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====Common findings==== | ====Common findings==== | ||
{{main|Adrenal gland}} | {{main|Adrenal gland}} | ||
*Cortical | *[[Adrenal cortical adenoma|Cortical adenoma]]s - seen in ~ 2% of autopsies.<ref name=pmid14514341>{{cite journal |author=Barzon L, Sonino N, Fallo F, Palu G, Boscaro M |title=Prevalence and natural history of adrenal incidentalomas |journal=Eur. J. Endocrinol. |volume=149 |issue=4 |pages=273–85 |year=2003 |month=October |pmid=14514341 |doi= |url=}}</ref> | ||
=====Others===== | =====Others===== | ||
*Atrophy. | *Atrophy - typically iatrogenic, may be [[Addison's disease]]. | ||
*Hyperplasia (bilateral). | *[[Adrenal cortical hyperplasia|Hyperplasia]] (bilateral). | ||
*Hemorrhage (Waterhouse-Friderichsen syndrome). | *Hemorrhage ([[Waterhouse-Friderichsen syndrome]]). | ||
*[[Metastatic]] cancer, esp. in the context of lung cancer. | |||
*[[Adrenal myelolipoma]]. | |||
===Stomach=== | ===Stomach=== | ||
*Opened along greater curvature. | *Opened along greater curvature. | ||
*GE junction should not be opened if portal hypertension is suspected (see: ''esophagus''). | **Large carcinomas preferentially involve the lesser curvature.<ref name=pmid2550682>{{Cite journal | last1 = Yamagawa | first1 = H. | last2 = Onishi | first2 = T. | title = [A clinicopathological study of early gastric cancers with a diameter larger than five centimeters]. | journal = Gan No Rinsho | volume = 35 | issue = 10 | pages = 1114-8 | month = Sep | year = 1989 | doi = | PMID = 2550682 }}</ref> | ||
*GE junction should not be opened if [[portal hypertension]] is suspected (see: ''esophagus''). | |||
====Findings==== | ====Findings==== | ||
{{Main|Stomach}} | |||
*Haemorrhage = usu. post-mortem. | *Haemorrhage = usu. post-mortem. | ||
*Small ~1 mm pellets ([http://www.gea-pharma.in/GPSIN/cmsresources.nsf/0/0514D214E17B10C0C125749B002640E1/$File/capsule_type.jpg medicinal capsule contents]). | *Small ~1 mm pellets ([http://www.gea-pharma.in/GPSIN/cmsresources.nsf/0/0514D214E17B10C0C125749B002640E1/$File/capsule_type.jpg medicinal capsule contents]). | ||
===Esophagus=== | ===Esophagus=== | ||
*Should be everted, if portal hypertension is suspected, as varices are thus more readily demonstrated.<ref name=Ref_HospAuto140>{{Ref HospAuto|140}}</ref> | {{Main|Esophagus}} | ||
*Should be everted, if [[portal hypertension]] is suspected, as [[esophageal varices]] are thus more readily demonstrated.<ref name=Ref_HospAuto140>{{Ref HospAuto|140}}</ref> | |||
*#Stomach opened (''without opening GE junction''). | *#Stomach opened (''without opening GE junction''). | ||
*#String tied to proximal esophagus. | *#String tied to proximal esophagus. | ||
*#Forceps inserted from stomach to grasp tied end and invert esophagus. | *#Forceps inserted from stomach to grasp tied end and invert [[esophagus]]. | ||
===Omentum=== | ===Omentum=== | ||
{{Main|Omentum}} | |||
*It is a good idea to trim this from the stomach. | *It is a good idea to trim this from the stomach. | ||
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{{Main|Spleen}} | {{Main|Spleen}} | ||
*Sugar-coated spleen. | *Sugar-coated spleen. | ||
**Properly referred to as ''hyaloserositis of the spleen''. | **Properly referred to as ''[[hyaloserositis of the spleen]]''. | ||
**Capsule of the spleen is white - resembles sugar-coating. | **Capsule of the spleen is white - resembles sugar-coating. | ||
**Importance: ''none'' - benign. | **Importance: ''none'' - benign. | ||
*Splenomegaly secondary to portal hypertension. | *[[Splenomegaly]] secondary to [[portal hypertension]]. | ||
===Kidney=== | ===Kidney=== | ||
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====Common pathologic findings==== | ====Common pathologic findings==== | ||
*Size of the kidney - small kidneys are seen in chronic renal failure. | *Size of the kidney - small kidneys are seen in chronic renal failure. | ||
**Normal adult kidney ~11 cm from pole-to-pole.<ref name=pmid20030823>{{Cite journal | last1 = Glodny | first1 = B. | last2 = Unterholzner | first2 = V. | last3 = Taferner | first3 = B. | last4 = Hofmann | first4 = KJ. | last5 = Rehder | first5 = P. | last6 = Strasak | first6 = A. | last7 = Petersen | first7 = J. | title = Normal kidney size and its influencing factors - a 64-slice MDCT study of 1.040 asymptomatic patients. | journal = BMC Urol | volume = 9 | issue = | pages = 19 | month = | year = 2009 | doi = 10.1186/1471-2490-9-19 | PMID = 20030823 | URL = http://www.biomedcentral.com/1471-2490/9/19 }}</ref> | |||
*Nephrosclerosis: | *Nephrosclerosis: | ||
**''Flea-bitten appearance'' - seen in hypertension.<ref name=pmid9356598>{{Cite journal | last1 = Ono | first1 = H. | last2 = Ono | first2 = Y. | title = Nephrosclerosis and hypertension. | journal = Med Clin North Am | volume = 81 | issue = 6 | pages = 1273-88 | month = Nov | year = 1997 | doi = | PMID = 9356598 }}</ref> | **''Flea-bitten appearance'' - seen in [[hypertension]].<ref name=pmid9356598>{{Cite journal | last1 = Ono | first1 = H. | last2 = Ono | first2 = Y. | title = Nephrosclerosis and hypertension. | journal = Med Clin North Am | volume = 81 | issue = 6 | pages = 1273-88 | month = Nov | year = 1997 | doi = | PMID = 9356598 }}</ref> | ||
*Acute tubular necrosis (ATN). | *[[Acute tubular necrosis]] (ATN). | ||
**ATN is difficult | **ATN is difficult to prove on autopsy material. | ||
** | **On microscopy, look for:<ref name=pmid19207286>{{Cite journal | last1 = Kocovski | first1 = L. | last2 = Duflou | first2 = J. | title = Can renal acute tubular necrosis be differentiated from autolysis at autopsy? | journal = J Forensic Sci | volume = 54 | issue = 2 | pages = 439-42 | month = Mar | year = 2009 | doi = 10.1111/j.1556-4029.2008.00956.x | PMID = 19207286 }}</ref> | ||
*** | ***Tubular epithelial whorls. | ||
*** | ***Tubulorrhexis. | ||
***Interstitial edema. | |||
===Liver=== | ===Liver=== | ||
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#Separated liver from abdominal pluck at ''porta hepatis''. | #Separated liver from abdominal pluck at ''porta hepatis''. | ||
#Open [[Gallbladder]]. | #Open [[Gallbladder]]. | ||
#Get mass. | #Get mass, i.e. weigh. | ||
#Slice axially - as seen on CT imaging. | #Slice axially - as seen on CT imaging. | ||
Notes: | Notes: | ||
*If there is a suspected biliary tract obstruction: | *If there is a suspected biliary tract obstruction: | ||
*#Open the duodenum (from distal end) and identify the ''duodenal papilla'' - this is usually obvious as everything distal to the duodenal papilla is usually light brown (bile-stained). | *#Open the [[duodenum]] (from distal end) and identify the ''duodenal papilla'' - this is usually obvious as everything distal to the duodenal papilla is usually light brown (bile-stained). | ||
*#Compress the gallbladder and bile should emerge from the duodenal papilla. | *#Compress the gallbladder and bile should emerge from the duodenal papilla. | ||
*#Disect bilary tree from duodenal papilla to the porta hepatis. | *#Disect bilary tree from duodenal papilla to the porta hepatis. | ||
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=====Liver===== | =====Liver===== | ||
{{Main|Liver}} | {{Main|Liver}} | ||
*Firm - suggests cirrhosis. | *Firm - suggests [[cirrhosis]]. | ||
*Micronodularity (with uniformity of the nodules) - suggestive of alcoholic cirrhosis. | *Micronodularity (with uniformity of the nodules) - suggestive of alcoholic cirrhosis. | ||
*Macronodularity (with heterogeneity of the nodules) - suggestive of viral hepatitis. | *Macronodularity (with heterogeneity of the nodules) - suggestive of [[viral hepatitis]]. | ||
*Yellow ''or'' pale liver: | *Yellow ''or'' pale liver: | ||
**DDx: | **DDx: | ||
**#Shock liver. | **#Shock liver. | ||
**#Steatosis ''or'' steatohepatitis. | **#[[Liver steatosis|Steatosis]] ''or'' [[steatohepatitis]]. | ||
*Congested (blood red/yellow) "nutmeg liver". | *Congested (blood red/yellow) "nutmeg liver". | ||
**Image: [http://www.pathology-india.com/nutmegliv1.JPG Nutmeg liver (pathology-india.com)]. | **Image: [http://www.pathology-india.com/nutmegliv1.JPG Nutmeg liver (pathology-india.com)]. | ||
=====Gallbladder===== | =====Gallbladder===== | ||
{{Main|Gallbladder}} | {{Main|Gallbladder}} | ||
* | *Gallstones ([[cholelithiasis]]). | ||
*Mucosa with strawberry-like appearance (cholesterolosis). | *Mucosa with strawberry-like appearance ([[cholesterolosis of the gallbladder|cholesterolosis]]). | ||
===Pancreas=== | ===Pancreas=== | ||
Line 283: | Line 390: | ||
**Corpus luteum - bright yellow (non-pathologic). | **Corpus luteum - bright yellow (non-pathologic). | ||
**Simple cyst. | **Simple cyst. | ||
{{Main|Uterus}} | |||
*Uterus: | |||
**Leiomyoma (uterine fibroid). | |||
{{Main|Urinary bladder}} | {{Main|Urinary bladder}} | ||
*Urinary bladder: | *Urinary bladder: | ||
Line 297: | Line 407: | ||
{{Main|Prostate gland}} | {{Main|Prostate gland}} | ||
*Prostate gland: | *Prostate gland: | ||
**Enlargement (benign prostatic hyperplasia). | **Enlargement ([[benign prostatic hyperplasia]]). | ||
{{Main|Urinary bladder}} | {{Main|Urinary bladder}} | ||
*Urinary bladder: | *Urinary bladder: | ||
**Trabeculation secondary to BPH. | **Trabeculation secondary to [[BPH]]. | ||
**Focal haemorrhage secondary to urinary catheter. | **Focal haemorrhage secondary to urinary catheter. | ||
==Skull & brain== | ==Skull & brain== | ||
===Opening the skull=== | |||
#One should saw through the skull completely, i.e. one should not "crack" the skull open with a chisel. | #One should saw through the skull completely, i.e. one should not "crack" the skull open with a chisel. | ||
#*Cracking open the skull may result in artefactual fractures that are impossible to differentiate from antemortem fractures. | #*Cracking open the skull may result in artefactual fractures that are impossible to differentiate from antemortem fractures. | ||
#*Cuts into the brain | #*Cuts into the brain from opening the skull ("city morgue sulcus") are ''not'' difficult to distinguish from antemortem injuries. | ||
===Extraction of the brain=== | |||
#Cranial nerves should be cut. | #Cranial nerves should be cut. | ||
#Tentorium should be released. | #Tentorium should be released. | ||
#Spinal cord should be completely cut as far down as possible. | #Spinal cord should be completely cut as far down as possible. | ||
#Dura should be stripped from the skull base. | #Dura should be stripped from the skull base (to look for [[bone fractures|fractures]]). | ||
Notes: | Notes: | ||
*Scalp hematoma: | *[[Scalp hematoma]]: | ||
**May result from intracranial pressure. | **May result from intracranial pressure. | ||
***[http://en.wikipedia.org/wiki/File:Scalp_hematomas.jpg Types of scalp hematomas]. | ***[http://en.wikipedia.org/wiki/File:Scalp_hematomas.jpg Types of scalp hematomas]. | ||
===Brain=== | ===Brain=== | ||
==== | Considerations for the retension of the brain (for prolonged [[fixation]]): | ||
*Survival interval in hospital. | |||
*Neurosurgical intervention. | |||
*Clinical Dx of [[DAI]]. | |||
*Hypoxic changes (make brain hard to cut). | |||
====Sectioning==== | |||
Up-down anatomically oriented (right side-up): | Up-down anatomically oriented (right side-up): | ||
#Examine meninges. | #Examine meninges. | ||
Line 347: | Line 466: | ||
===Starvation=== | ===Starvation=== | ||
{{Main|Starvation}} | |||
*Serous fat atrophy. | *Serous fat atrophy. | ||
**Gross appearance: brown goo replaces fat. | **Gross appearance: brown goo replaces fat. | ||
***May be associated with blood vessel tortuosity.<ref>KC. 14 September 2010.</ref> | ***May be associated with blood vessel tortuosity.<ref>KC. 14 September 2010.</ref> | ||
=Histology= | |||
===General=== | ===General=== | ||
It's the at the pathologists discretion. In ''decomp'' cases it is reasonable to submit nothing. | It's the at the pathologists discretion. In ''[[decomp]]'' cases it is reasonable to submit nothing. | ||
===Forensic context=== | ===Forensic context=== | ||
A standard (minimum) for adult homicides is: | A standard (minimum) for adult homicides is: | ||
#Heart (1). | #[[Heart]] (1). | ||
#Lung (1). | #[[Lung]] (1). | ||
#Liver (1). | #[[Liver]] (1). | ||
#Kidney (1). | #[[Kidney]] (1). | ||
===Hospital autopsies=== | ===Hospital autopsies=== | ||
====Non- | ====Non-neuropathology==== | ||
A standard based on a Toronto teaching hospital: | |||
*[[Thyroid gland]] (1). | *[[Thyroid gland]] (1). | ||
*[[Lung]] - each lobe (5). | *[[Lung]] - each lobe (5). | ||
Line 408: | Line 493: | ||
*[[Adrenal gland]] (1). | *[[Adrenal gland]] (1). | ||
*Gastrointestinal tract: | *Gastrointestinal tract: | ||
**The quality | **The quality is often very poor (even in "fresh" bodies). These are often omitted. | ||
***[[Pancreas]] - head & tail (1). | ***[[Pancreas]] - head & tail (1). | ||
***[[Stomach]] (1). | ***[[Stomach]] (1). | ||
Line 419: | Line 504: | ||
***Male: | ***Male: | ||
****[[Prostate gland]] (1). | ****[[Prostate gland]] (1). | ||
****Testis (1). | ****[[Testis]] (1). | ||
***Female: | ***Female: | ||
****Uterus +/- cervix (1). | ****[[Uterus]] +/- cervix (1). | ||
****Ovary + tube (1). | ****[[Ovary]] + tube (1). | ||
*Bone marrow (1). | *[[Bone marrow]] (1). | ||
====Neuro==== | ====Neuro==== | ||
*Pituitary gland (1). | *[[Pituitary gland]] (1). | ||
*Cortex usu. frontal/parietal (1). | *Cortex usu. frontal/parietal (1). | ||
*Hippocampus (1). | *[[Hippocampus]] (1). | ||
*Cerebellum (1). | *Cerebellum (1). | ||
*Brain stem (1). | *Brain stem (1). | ||
Line 439: | Line 525: | ||
**Tissue with AV node. | **Tissue with AV node. | ||
*Lung - all five lobes. | *Lung - all five lobes. | ||
*Spleen. | *[[Spleen]]. | ||
*Urinary: | *Urinary: | ||
**Kidney. | **Kidney. | ||
Line 448: | Line 534: | ||
**Small bowel. | **Small bowel. | ||
**Large bowel. | **Large bowel. | ||
**Appendix. | **[[Appendix]]. | ||
**Pancreas (head & tail). | **[[Pancreas]] (head & tail). | ||
**Liver. | **Liver. | ||
*Reproductive: | *Reproductive: | ||
**Male: | **Male: | ||
***Prostate gland. | ***[[Prostate gland]]. | ||
***Testis. | ***[[Testis]]. | ||
**Female: | **Female: | ||
***Breast. | ***[[Breast]]. | ||
***Uterus. | ***[[Uterus]]. | ||
***Ovary. | ***[[Ovary]]. | ||
*Neurologic: | *Neurologic: | ||
**Hippocampus + basal ganglia. | **Hippocampus + basal ganglia. | ||
Line 467: | Line 553: | ||
*Nerve. | *Nerve. | ||
*Muscle. | *Muscle. | ||
*Lymph nodes. | *[[Lymph nodes]]. | ||
=Autopsy report= | |||
==Normal size parameters== | |||
===Normal organ masses (adult)=== | |||
Caucasoid population of 684 adults:<ref name=pmid11376980>{{cite journal |author=de la Grandmaison GL, Clairand I, Durigon M |title=Organ weight in 684 adult autopsies: new tables for a Caucasoid population |journal=Forensic Sci. Int. |volume=119 |issue=2 |pages=149–54 |year=2001 |month=June |pmid=11376980 |doi= |url=}}</ref> | |||
{| class="wikitable" | |||
| | |||
|'''Men''' | |||
|'''Women''' | |||
|- | |||
|'''Heart''' | |||
|365 +/- 71 g | |||
|312 +/- 78 g | |||
|- | |||
|'''Right lung''' | |||
|663 +/- 239 g | |||
|546 +/- 207 g | |||
|- | |||
|'''Left lung''' | |||
|583 +/- 216 g | |||
|467 +/- 174 g | |||
|- | |||
|'''Liver''' | |||
|1677 +/- 396 g | |||
|1475 +/- 362 g | |||
|- | |||
|'''Spleen''' | |||
|156 +/- 87 g | |||
|140 +/- 78 g | |||
|- | |||
|'''Right kidney''' | |||
|162 +/- 39 g | |||
|135 +/- 39 g | |||
|- | |||
|'''Left kidney''' | |||
|160 +/- 41 g | |||
|136 +/- 37 g | |||
|} | |||
===Pediatrics=== | |||
{{Main|Growth charts}} | |||
==Negative autopsy== | ==Negative autopsy== | ||
Line 477: | Line 604: | ||
*Unascertained. | *Unascertained. | ||
===Considerations | ===Considerations=== | ||
*Channelopathy | *[[Channelopathy]] - may be elucidated by molecular testing. | ||
*Electrocution (unrecognized). | *[[Electrocution]] (unrecognized). | ||
*Decomposition. | *Decomposition. | ||
*Sudden Unexpected Death in Epilepsy (SUDEP)<ref>URL: [http://emedicine.medscape.com/article/1187111-overview http://emedicine.medscape.com/article/1187111-overview]. Accessed on: 11 October 2010.</ref> - missing history. | *Sudden Unexpected Death in [[Epilepsy]] ([[SUDEP]])<ref>URL: [http://emedicine.medscape.com/article/1187111-overview http://emedicine.medscape.com/article/1187111-overview]. Accessed on: 11 October 2010.</ref> - missing history. | ||
*[[Sudden infant death syndrome]]. | |||
==Histology checklist== | |||
{| class="wikitable sortable" | |||
! Section/organ | |||
! Expected finding(s)/common finding(s) | |||
! Findings to consider | |||
|- | |||
| [[Bone marrow]] | |||
| | |||
*trilineage hematopoiesis | |||
| | |||
*infection | |||
*tumour | |||
|- | |||
| [[Coronary arteries]] | |||
| | |||
*[[atherosclerosis]] - should give percent stenosis for major arteries (LMCA, LAD, LCx, RCA) | |||
| | |||
*atherosclerotic plaque rupture | |||
*thrombi | |||
*inflammation | |||
|- | |||
| [[Heart]] muscle | |||
| | |||
*fibrosis - esp. post. LV (old [[myocardial infarction|MI]]) | |||
*nuclear enlargement, arteriolosclerosis, periarteriolar fibrosis ([[hypertensive heart disease]]) | |||
| | |||
*hemorrhage | |||
*wavy fibres (early ischemic change) | |||
*[[necrosis]] - coagulative/contraction band (recent MI) | |||
*inflammatory infiltrate - not associated with necrosis | |||
*hyaline material ([[cardiac amyloidosis]]) | |||
*fibre disarray ([[hypertrophic cardiomyopathy]]) | |||
*fatty replacement ([[ARVC]]) | |||
|- | |||
| [[Adrenal gland]] | |||
| | |||
*no pathology | |||
| | |||
*tumour | |||
**primary (cortex, medulla) | |||
**metastatic | |||
*hemorrhage | |||
*fat | |||
|- | |||
| [[Kidney]] | |||
| | |||
*vessels (atherosclerosis, [[arterial hyaline|arteriolar hyalinization]]) | |||
| | |||
*tumour | |||
*glomeruli (enlargement, crescents, [[mesangial expansion]], inflammation - esp. [[PMN]]s) | |||
*vessels - thrombi ([[thrombotic microangiopathy]]) | |||
*interstitial (fibrosis, inflammation, edema) | |||
*tubules (inflammation, tubular epithelial whorls, tubulorrhexis) | |||
|- | |||
| [[Liver]] | |||
| | |||
*steatosis - should give severity (mild, mederate, severe), location & type (macrovesicular vs. microvesicular) | |||
| | |||
*fibrosis (septa, rounded contours, [[cirrhosis]]), inflammation (cell type, location (portal, interface, lobular)) | |||
*tumour - esp. metastatic | |||
*bile ducts | |||
*[[ballooning degeneration]] ([[steatohepatitis]])/feathery degeneration ([[cholestasis]]) | |||
*necrosis (location important) | |||
|- | |||
| [[Spleen]] | |||
| | |||
*normal white pulp/red pulp | |||
| | |||
*tumour | |||
*surface abnormalities | |||
|- | |||
| Gastrointestinal tract | |||
| | |||
*autolytic changes | |||
| | |||
*tumour | |||
*vessels | |||
*inflammation - esp. [[PMN]]s | |||
*fibrosis | |||
|- | |||
| [[Thyroid gland]] | |||
| | |||
*no pathology | |||
| | |||
*tumour - papillary thyroid carcinoma, goitre | |||
*inflammation | |||
|- | |||
| [[Lung pathology|Lung]] | |||
| | |||
*pulmonary edema | |||
*[[emphysema]] | |||
| | |||
*infectious pneumonia | |||
*[[pulmonary hypertension]] (may be focal) | |||
*interstitial fibrosis | |||
*tumour | |||
*[[granuloma]]s | |||
*hemorrhage | |||
*hyaline membranes ([[diffuse alveolar damage]]) | |||
|} | |||
===List form=== | |||
====Bone marrow==== | |||
*Trilineage hematopoiesis present. | |||
*Negative for infection and negative for tumour. | |||
====Cardiovascular system==== | |||
[[Coronary arteries]]: | |||
*[[Atherosclerosis]] in the: | |||
**Left main coronary artery. | |||
**Left anterior descending coronary artery. | |||
**Left circumflex coronary artery. | |||
**Right coronary artery. | |||
*No identified atherosclerotic plaque rupture. | |||
*No thrombosis. | |||
*No vasculitis. | |||
[[Heart]] muscle: | |||
*Fibrosis - posterior left ventricle. | |||
*Nuclear enlargement, arteriolosclerosis and periarteriolar fibrosis. | |||
*No hemorrhage. | |||
*No wavy fibres. | |||
*No [[necrosis]]. | |||
*No inflammatory infiltrate. | |||
*No hyaline material. | |||
====Endocrine organs==== | |||
[[Adrenal gland]]: | |||
*No pathology apparent. | |||
*No tumour. | |||
*No hemorrhage. | |||
*No fatty replacement. | |||
Thyroid gland: | |||
*Normal thyroid gland. | |||
*No tumour. | |||
*No inflammation. | |||
====Genitourinary system==== | |||
[[Kidney]]: | |||
*Atherosclerosis, mild. | |||
*Arteriolar hyalinization. | |||
*No tumour. | |||
*Normal glomeruli (no enlargement, no crescents, no [[mesangial expansion]], no inflammation). | |||
*No thrombi. | |||
*No interstitial fibrosis, no inflammation, and no edema. | |||
*No tubular inflammation, no whorls, and no fragmentation. | |||
*No apparently pathologic renal casts. | |||
====Gastrointestinal system==== | |||
[[Liver]] | |||
*Steatosis - mild, centrilobular, macrovesicular. | |||
*No fibrosis. | |||
*No inflammation. | |||
*No tumour. | |||
*Normal bile ducts. | |||
*No [[ballooning degeneration]] and no feathery degeneration. | |||
*No necrosis. | |||
Luminal GI tract: | |||
*Autolytic changes. | |||
*No tumour | |||
*No vasculitis. | |||
*No siginificant atherosclerosis. | |||
*No inflammation. | |||
*No fibrosis. | |||
====Spleen==== | |||
*Normal white pulp/red pulp. | |||
*No tumour. | |||
*No surface abnormalities. | |||
====Lung==== | |||
*Pulmonary edema. | |||
*Infectious pneumonia, mild. | |||
*Emphysema, mild. | |||
*No pulmonary hypertension. | |||
*No interstitial fibrosis. | |||
*No tumour, | |||
*No granulomas, | |||
*No significant hemorrhage. | |||
*No hyaline membranes. | |||
==Sign out== | |||
===Sample clinical history=== | |||
<pre> | |||
A 63 year old male with a history of alcohol abuse was admitted on December 13, 2022 for | |||
recurrent alcohol related pancreatitis. On December 21, he was found unresponsive at 0:15. | |||
Approximately fifteen minutes earlier, he was on oxygen and in no apparent distress. A code | |||
blue was called; however, the attempted resuscitation was unsuccessful. Death was declared | |||
at 1:00 on December 21, 2022. | |||
</pre> | |||
=See also= | |||
*[[Fetal autopsy]]. | *[[Fetal autopsy]]. | ||
*[[Forensic pathology]]. | *[[Forensic pathology]]. | ||
=References= | |||
{{reflist|2}} | {{reflist|2}} | ||
=External links= | |||
[[Category:Autopsy]] | [[Category:Autopsy]] |
edits