Autopsy

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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.

Contents

Value of autopsy

A significant number of major findings cannot be diagnosed without histology;[1] 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:[2]

  • 25% of autopsies reveal a finding that would have changed clinical management.
  • 5% of autopsies reveal a missed diagnosis that probably affected the outcome.

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.[3]

Hierarchy

If the executor of the estate is not specified the hierarchy is as follows:[3]

  1. 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).
  2. If no spouse, any children 16+ years old,
  3. If no children, either parent,
  4. If no parent, any brother or sister 16+ years old,
  5. If no sibling, any next-of-kin 16+ years old,
  6. If no next-of-kin, the person lawfully in possession of the body (not the hospital).

Notes:

  • Exact hierarchy may vary by jurisdiction.
  • 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

  • There are religious objections to autopsy among Jews and Muslims.[4][5]
  • 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.

Timeliness

There are turnaround time standards from the College of American Pathologists:[6]

Deliverable Time Comment
Provisional report 2 working days gross findings & history
"Most" final reports 30 days
All final reports 60 days

External exam

General

  • Very important in the forensic context.
  • Medical devices, tubes and lines should be left in situ to allow the determination of their precise location within the body;[7] it is very difficult to determine what the location of a line was once it is removed.

Extremities

  • Fingers should be identified by name (e.g. ring finger), as some people number the digits 1-4 and consider the thumb separately, while others number 'em 1-5.[8]

Body should be examined for defensive-type wounds:

  • Between the fingers - especially thumb and pointing finger.
  • Dorsal aspect of the hand.
  • Forearm.

Findings

Internal exam

General

  • This is usually where the money is in hospital autopsies.
  • Like surgeons say... you should never cut anything until you're sure what it is.

Before the first incision

If there is suspicion of pneumothorax - one the the three following can be done:[9]

  1. Create a "pleural window" (between ribs by removing soft tissue... without entering the pleural cavity).
  2. Open chest underwater and watch for air bubbles.
  3. Needle puncture with water filled syringe - where plunger has been removed.
  • 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.[10]
    • 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

  • Y-shaped incision (standard):
    • Superior "points" of the Y ~ at the deltoid muscle.
    • "Confluence of lines" in the Y ~ inferior to the suprasternal notch.
  • Neck dissection incisions:
    • 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.

Notes:

  • The sternum may have cleft or foramen - as an anatomical variant.[11]
  • 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

Feature/time Pre-mortem Post-mortem
Shininess dull shiny
Adherent to wall yes[12] no
Colour grey; may have zebraic
appearance (lines of Zahn) -
red alt. with grey/yellow
dark purple or
bilayered yellow/red
Pressurized yes; "ejects itself" from lumen no; needs to be pulled-out
Consistency
-elastic modulus (E)
-fracture toughness (K)
firm (high E)
brittle (low K)
jello (low E)
elastic (high K)
Image - gross thrombus (pathguy.com),
thrombus (thrombosisadviser.com)
coronary thrombus (luc.edu)[13]
Image - micro. pre- & post-mortem (elsevier.es)[14] thrombus (oxfordjournals.org),
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"

One piece (standard):

  • Diaphragm cut: at chest wall.
  • Superior cut: through arch vessels.
  • Inferior cut: through the common iliac vessels.
  • Posterior:
    • Thorax: cut paravertebral.
    • Abdomen: blunt dissection for kidneys, then paravertebral.

Two pieces (thorax & abdomen):

  • May be preferred in a "glued" (fibrosed/post-surgical) abdomen.
  • Procedure - similar to one piece but:
    • Cut aorta distal to the left subclavian + detach from thoracic pluck.
    • Cut esophagus distal to pharynx + detach from thoracic pluck.

Neck organ pluck

Non-suspicious cases

  1. Trim tissue posterior to horns of the thyroid.
  2. Cut between thyroid horns & hyoid.
  3. 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.[15]

Hyoid bone

  • Important in forensic pathology.
  • Fracture is seen in manual strangulation.
  • May appear fractured if triticeous cartilage (or triticeal cartilage) is present;[16][17] triticeous cartilage may be confused with a fragment of hyoid bone.
    • Triticeous is pronounced tri-tish´us.[18]

Larynx injury

These are worked-up in great detail in Germany.[19] 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

Process

  1. Place organ pluck with anterior aspect down.
  2. Open aorta (posterior aspect - from just distal to subclavian + common iliacs).
    • Probe celiac trunk, SMA, renal arteries, IMA.
    • Open renal arteries.
  3. Blunt dissection to separate aorta from thorax distal to left subclavian artery.
  4. Cut through aorta distal to left subclavian artery.
  5. Separate aorta from pluck.
  6. Open IVC to diaphragm.
    • Check renal veins.
  7. Separate IVC.
  8. Transect esophagus (~2 cm) distal to inferior margin of the cricoid cartilage.
  9. Take down esophagus using blunt dissection (to separate from thorax).
  10. Separate thorax and abdomen - by dissecting through the pericardium.

Common finding(s)

Things to think about

Thoracic pluck

Heart

  • Dissection - see Heart article.
  • Conducting system - see Heart article.

Respiratory system

  1. Open trachea + bronchus (see Note).
  2. Examine proximal airway.
  3. Examine proximal pulmonary arteries.
    • May be done from intralobular fissures.[20]
      • The large arteries of the right lung is found deep to oblique fissure.[21]
  4. Slice lungs - one lobe at a time (easier to cut).
  5. Squeeze lungs - to test for the presence of pus and edema fluid.[21]

Note:

  • If the lungs are to be inflated the bronchi should be left long.

Common findings

  • Plural adhesions.
  • Plural effusions.
    • Types: serous (clear), serosaginous (cloudy), serofibrinous (clotted/webbed), purulent (yellow).
  • Edema - fluid comes-out when you squeeze 'em, "heavy" (large mass).
  • 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.[22]

Abdominal organ pluck

Adrenal glands

  1. Place cuts at anatomical location.
  2. Take section for stock.

Common findings

Others

Stomach

  • Opened along greater curvature.
    • Large carcinomas preferentially involve the lesser curvature.[24]
  • GE junction should not be opened if portal hypertension is suspected (see: esophagus).

Findings

Esophagus

  • Should be everted, if portal hypertension is suspected, as esophageal varices are thus more readily demonstrated.[25]
    1. Stomach opened (without opening GE junction).
    2. String tied to proximal esophagus.
    3. Forceps inserted from stomach to grasp tied end and invert esophagus.

Omentum

  • It is a good idea to trim this from the stomach.

Spleen

  1. Separate stomach from spleen.
  2. Identify the splenic vessels.
  3. To separate the spleen from the pluck:
    • Cut across vessels at splenic hilum - close to the spleen.

Common findings

Kidney

  • Renal vein & artery already examined.
  1. +/-Open ureter.
  2. Strip capsule.
  3. Left ureter is left long - to tell apart the kidneys.
  4. Kidney (nearly) bisected in coronal plane from anti-ureteric surface; a small rim of tissue is left on the hilar (or ureteric) aspect -- to keep the kidney as one piece.[26]

Common pathologic findings

  • Size of the kidney - small kidneys are seen in chronic renal failure.
    • Normal adult kidney ~11 cm from pole-to-pole.[27]
  • Nephrosclerosis:
  • Acute tubular necrosis (ATN).
    • ATN is difficult to prove on autopsy material.
    • On microscopy, look for:[29]
      • Tubular epithelial whorls.
      • Tubulorrhexis.
      • Interstitial edema.

Liver

  1. Remove diaphragm (with scissors).
  2. Separated liver from abdominal pluck at porta hepatis.
  3. Open Gallbladder.
  4. Get mass, i.e. weigh.
  5. Slice axially - as seen on CT imaging.

Notes:

  • If there is a suspected biliary tract obstruction:
    1. 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).
    2. Compress the gallbladder and bile should emerge from the duodenal papilla.
    3. Disect bilary tree from duodenal papilla to the porta hepatis.

Common pathologic findings

Liver
Gallbladder

Pancreas

  • Serially section along axis of pancreatic duct.
  • Pieces of head & tail for stock or stock and histology.

Genitourinary-rectal or pelvic pluck

Female[30]

  1. Orient rectum down, bladder up.
  2. Open bladder with scissors via urethra with cuts in sagittal plane.
  3. Flip over specimen.
  4. Open rectum with scissors with cuts in the sagittal plane.
  5. Flip over specimen.
  6. Open vagina with cuts on its lateral aspect.
  7. Open cervix & uterus with cuts on its lateral aspect.
  8. Bisect ovaries.

Common pathologic findings

  • Ovary:
    • Corpus luteum - bright yellow (non-pathologic).
    • Simple cyst.
  • Uterus:
    • Leiomyoma (uterine fibroid).
  • Urinary bladder:
    • Focal haemorrhage secondary to urinary catheter.

Male

  1. Orient rectum down, bladder up.
  2. Open bladder with scissors via urethra/prostate with cuts in sagittal plane.
  3. Serially section prostate in the planes defined by the axis of the urethra.
  4. Flip over specimen.
  5. Open rectum with scissors with cuts in the sagittal plane.

Common pathologic findings

  • Urinary bladder:
    • Trabeculation secondary to BPH.
    • Focal haemorrhage secondary to urinary catheter.

Skull & brain

Opening the skull

  1. 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.
    • Cuts into the brain from opening the skull ("city morgue sulcus") are not difficult to distinguish from antemortem injuries.

Extraction of the brain

  1. Cranial nerves should be cut.
  2. Tentorium should be released.
  3. Spinal cord should be completely cut as far down as possible.
  4. Dura should be stripped from the skull base (to look for fractures).

Notes:

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):

  1. Examine meninges.
  2. Remove dura.
  3. Examine venous sinuses.
  4. Look for gyri effacement - due to edema or haematomas.

Not up-down anatomically oriented (top down):

  1. Remove brain stem - with one cut ~ at level of mid-brain.
  2. Cerebrum section - first cut at mammillary bodies.
    • Subsequent cuts ~ 1.0 cm in thickness.

Anatomic variants

  • Metopic suture - midline in frontal bone.[31]
  • Wormian bones = "extra" bone at the sutures in the skull.

Anatomy

  • Lambdoidal suture - occipital bone/parietal bones.
  • Coronal suture - frontal bone/parietal bone.

Weird stuff

  • Methylene blue, used for refractory shock,[32] turns organs green.[33]
  • Hyperviscosity syndrome - in leukemia.[34]

Starvation

  • Serous fat atrophy.
    • Gross appearance: brown goo replaces fat.
      • May be associated with blood vessel tortuosity.[35]

Histology

General

It's the at the pathologists discretion. In decomp cases it is reasonable to submit nothing.

Forensic context

A standard (minimum) for adult homicides is:

  1. Heart (1).
  2. Lung (1).
  3. Liver (1).
  4. Kidney (1).

Hospital autopsies

Non-neuropathology

A standard based on a Toronto teaching hospital:

Neuro

Stock

  • Thyroid gland.
  • Heart:
    • Complete (axial) slice (including RV and LV).
    • Tissue with SA node.
    • Tissue with AV node.
  • Lung - all five lobes.
  • Spleen.
  • Urinary:
    • Kidney.
    • Urinary bladder.
  • Gastrointestinal tract:
    • GE junction.
    • Stomach.
    • Small bowel.
    • Large bowel.
    • Appendix.
    • Pancreas (head & tail).
    • Liver.
  • Reproductive:
  • Neurologic:
    • Hippocampus + basal ganglia.
    • Cortex.
    • Brainstem.
    • Cerebellum.
  • Skin.
  • Nerve.
  • Muscle.
  • Lymph nodes.

Autopsy report

Normal size parameters

Normal organ masses (adult)

Caucasoid population of 684 adults:[36]

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

Negative autopsy

Definition:

  • A negative autopsy is a post-mortem exam that has no anatomical or toxicological cause of death.
    • This does not preclude the presence of pathology (that is not sufficient to cause death).

Cause of death (in a negative autopsy):

  • Unascertained.

Considerations

Histology checklist

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
Adrenal gland
  • no pathology
  • tumour
    • primary (cortex, medulla)
    • metastatic
  • hemorrhage
  • fat
Kidney
  • tumour
  • glomeruli (enlargement, crescents, mesangial expansion, inflammation - esp. PMNs)
  • 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)
Spleen
  • normal white pulp/red pulp
  • tumour
  • surface abnormalities
Gastrointestinal tract
  • autolytic changes
  • tumour
  • vessels
  • inflammation - esp. PMNs
  • fibrosis
Thyroid gland
  • no pathology
  • tumour - papillary thyroid carcinoma, goitre
  • inflammation
Lung

List form

Bone marrow

  • Trilineage hematopoiesis present.
  • Negative for infection and negative for tumour.

Cardiovascular system

Coronary arteries:

  • Atherosclerosis -
    • Left main coronary artery 30%.
    • Left anterior descending coronary artery 75%.
    • Left circumflex coronary artery 30%.
    • Right coronary artery 85%.
  • 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

A 63 year old male with a history of alcohol abuse was admitted on December 13, 2018 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, 2018.

See also

References

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  2. Brian Gallagher, Burton EC, McDonald KM, Goldman L (2003). "Changes in rates of autopsy-detected diagnostic errors over time: a systematic review". JAMA 289 (21): 2849–56. doi:10.1001/jama.289.21.2849. PMID 12783916.
  3. 3.0 3.1 URL: http://www.docstoc.com/docs/51609856/CONSENT-FOR-AUTOPSY. Accessed on: 27 September 2010.
  4. Burton, Julian L.; Rutty, Guy N. (2010). The Hospital Autopsy A Manual of Fundamental Autopsy Practice (3rd ed.). Oxford University Press. pp. 43. ISBN 978-0340965146.
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  11. Fokin AA (May 2000). "Cleft sternum and sternal foramen". Chest Surg. Clin. N. Am. 10 (2): 261–76. PMID 10803333.
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  13. URL: http://www.meddean.luc.edu/lumen/meded/mech/cases/case1/list.htm. Accessed on 8 October 2010.
  14. URL: http://www.elsevier.es/cardio_eng/ctl_servlet?_f=40&ident=13142654. Accessed on: 8 October 2010.
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  18. URL: http://medical-dictionary.thefreedictionary.com/triticeous. Accessed on: 15 September 2010.
  19. Evgenij Gazov. LMU Rechtsmedizin. 8 July 2011. Possibly described more here: http://www.reference-global.com/doi/abs/10.1515/9783899496079.1027
  20. Ali-Ridha, HN. 8 October 2010.
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  30. Burton, Julian L.; Rutty, Guy N. (2010). The Hospital Autopsy A Manual of Fundamental Autopsy Practice (3rd ed.). Oxford University Press. pp. 130. ISBN 978-0340965146.
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