Fatal intra-abdominal hemorrhage as a result of avulsion of the gallbladder: a postmortem case report
A man in his 40s with a history of chronic alcohol abuse and mental illness was found dead at home. His brother alleged that he hit the deceased's head and face while under the influence of alcohol, but in a deposition he denied hitting the deceased in the abdomen. During the police investigation, the veracity of the brother's account could not be determined because he was intoxicated at the time of the incident. He also had a mental illness. Therefore, the body was transported to our institution for a forensic autopsy in order to clarify whether the death was the result of a crime or an accident.\nPostmortem CT for pre-autopsy screening was performed with an eight-channel multislice scanner (Aquilion; Toshiba Medical Systems, Tokyo, Japan). Images were reconstructed with soft tissue, lung, and bone kernels to provide 2.0 mm slices each. MSCT data were sent to a digital imaging and communication in medicine (DICOM) server (POP-Net Server; ImageONE, Tokyo, Japan) and a three-dimensional workstation (ziostation ver. 2.1.0.3; Ziosoft, Tokyo, Japan). All CT images were evaluated by an experienced radiologist.\nOn postmortem CT, a moderate amount of blood was identified in the right perihepatic and perisplenic spaces, respectively (Fig. a). The gallbladder could not be visualized in situ (Fig. b). It was lying in a high-attenuation material (suspected to be blood) in the inferior abdomen, detached from its liver bed and filled with a large amount of bile, some gallstones, and biliary sludge (Fig. c, d, e). Its fundus was at the lower pole of the right kidney (Fig. d). Clotted blood was evident in the liver bed (Fig. b). No other hepatic parenchymal injuries were visible on CT. Other CT findings included fatty liver, fractures of the fourth to ninth left ribs, and cerebral edema. Pneumothorax and hemothorax were not found.\nFollowing MSCT scanning, forensic autopsy was performed with the guidance of radiologic findings. The cadaver was 170 cm long and weighed 92 kg. The subcutaneous tissue of the head was edematous. The brain weighed 1200 g, with slight swelling of the surface. No intracranial bleeding was identified. Slight amounts of subcutaneous hemorrhage were widespread in the upper abdomen. Massive subcutaneous hemorrhage was seen around the left thoracic and left hip region. The eighth right costal cartilage and the fifth and sixth left costal cartilages were fractured. The multiple bilateral rib fractures were found without pleural injury. There were no lacerations and hemorrhage in both lungs. The distended gallbladder was completely stripped from its liver bed (Fig. ) and hanging from an intact cystic duct with adherent coagulated material. The gallbladder was filled with dark green bile (110 mL) and three gallstones, and associated with massive intra-abdominal bleeding (900 mL). There was no extrahepatic bile duct injury or evidence of bile leak. The presence of clotted blood was confirmed on the liver bed. The liver weighed 1580 g; the appearance of its external surface was irregular, nodular, and yellow. The cut surface also had a yellow granular appearance suggestive of cirrhosis. No other pathological abnormalities were found in the abdomen.\nThe blood alcohol concentration was 0.8 mg/mL. As mentioned above, we confirmed that the brain and lungs showed no significant pathological alteration, and therefore concluded that the cause of death was hemorrhagic shock due to intra-abdominal bleeding from avulsion of the gallbladder.