Determination of cause of death in natural deaths, particularly when the death occurred suddenly, unexpectedly, is an important part of forensic autopsy. Acute pancreatic disease is one of the such causes. Careful attention should be paid to diagnose the particular disease to opine cause of death.
The pancreatic enzyme amylase and lipase are must commonly used to confirm the diagnosis of pancreatitis. Researchers have identified a new biomarker for pancreatic injury: “Plasma miR-216a ”. Plasma miR-216a might serve as a candidate marker of pancreatic injury with novel specificity.
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http://www.wjgnet.com/1007-9327/16/4599.pdf
The most sensitive marker is lactoferrin (staining) to visualise degranulation in the exocrine pancreas, however, it cannot determine the cause of death.
Dr.Löhr, do you believe that degranulation of the acinar cells is the most reliable sign of the acute pancreatitis? Will you explain this, please?
True sudden and unexpected death due to acute pancreatitis is rare. However most of the cases have acute hemorrhagic pancreatitis which is not problematic to diagnose during the autopsy. There are also anecdotal cases of fatty necroses in lipomatous heart as a cause of sudden death in AP. However it seems that underlying hearth/vascular/brain disease is an important prerequisite for sudden death in AP. If you cannot find the pancreatitis during the autopsy and regular histology it is unlikely AP to be a cause of death. Look at the some papers below:
http://www.ncbi.nlm.nih.gov/pubmed/22079999
http://www.ncbi.nlm.nih.gov/pubmed/20650420
http://www.ncbi.nlm.nih.gov/pubmed/17721182
http://www.ncbi.nlm.nih.gov/pubmed/17209933
IMHO, Dr.Julianov gave the excellent and exhaustive answer. Thank you!
I agree with A.Julianov. An established acute pancreatitis , sufficient enough
to contribute directly to death, is obvious on gross examination with no need usually for histology examination.
This can be a true dilemma. Pathologists sometimes face the problem of differentiating between (i) acute pancreatitis as a primary cause of death; (ii) secondary acute pancreatitis due to, for example, hypotension following cardiac surgery bypass or a massive myocardial infarction with acute heart failure; (iii) 'normal' post-mortem pancreatic autolysis which worsens in severity as times elapses after death. The first two will look very similar obviously, both within the abdomen and also systemic complications (ARDS can compicate both acute pancreatitis and any other cause of prolonged hypotension), but in post-mortem autolysis necrosis will usually be restricted to the pancreas (and gut mucosa) without the more widespread fat necrosis throughout the abdomen, and as Dr Julianivc sometimes even more remotely, that accompanies true acute pancreatitis. Histology would only help to differentiate pancreatic necrosis from peripancreatic necrosis which can make the exterior surface of the gland look necrotic, until the gland is sectioned, but the macroscopic appearances around the pancreas should usually suffice as stated by Ali Hussein and Dr Julianov Clearly it is important that clinicians pass on any relevant information on history, examination and investigation finding to the pathologist, and ideally a clinician should be present at the autopsy. Sudden ''apoplectic' death from acute pancreatitis is rare but is described in the literature and can occur in young patients. There is usually no true haemorrhage in acute pancreatitis, the haemorrhagic appearancs are due to digestion of haemoglobin producing methaemalbumen. The same process occurs in body wall bruising such as the Grey-Turner's and Cullen's signs around the flanks and umbilicus. Good communication between clinicians and the pathologist is essential when trying to ascertain the true cause of death.
Couldn't agree more with Michael. When I was a doctoral student and fellow with Günter Klöppel, THE pancreatic pathologist, we saw ONE case of pancreas apoplex: a darkgreen pancreas. Never saw anything else before like that.
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