A Fatal Complex Case of Extensive Digestive Necrosis – Was it Trauma, Intoxication or Ischemia?

Abstract

Introduction

Extensive necrosis of the upper digestive tract is an uncommon and life-threatening condition, usually associated with severe ischemia, toxic agents, or considerable abdominal trauma. Determining the primary cause might be challenging when other factors, such as systemic vascular disease or delayed hospital presentation, are involved. Instances of simultaneous necrosis in multiple organs are rarely recorded in the literature. We present a fatal case of widespread digestive necrosis in a patient with recent thoraco-abdominal trauma, history of homemade herbal products use, and extensive hyaline arteriolosclerosis.

Case Report

A 66-year-old woman with a history of type II diabetes mellitus and previous colectomy presented to the emergency room four days after a domestic fall. Clinical and imaging assessments revealed fluido-pneumothorax, considerable stomach distension, hemoperitoneum, several mesenteric and splenic hematomas. An emergency exploratory laparotomy confirmed the intra-abdominal trauma, but also gastrointestinal necrosis at different levels. A total gastrectomy, terminal abdominal esophagostomy, segmental small bowel resection, splenectomy, and jejunostomy were performed. Frozen section examination revealed transmural necrosis of the esophagus, stomach, and duodenum, severe ischemic enteritis, and considerable haemorrhagic extravasation. Despite the extensive postoperative care, the patient experienced significant hemodynamic instability, resulting in cardiac arrest and subsequent death. A forensic autopsy was required and performed at the Institute of Forensic Medicine - Târgu Mureș, due to trauma sustained prior to admission. A notable microscopic finding was generalized hyaline arteriolosclerosis involving small-calibre vessels in multiple organs, including the heart, kidneys, lungs, and gastrointestinal tract. Comprehensive toxicological testing of the blood and specimens yielded no evidence supporting a toxic etiology.

Conclusions

The present case illustrates how trauma, delayed hospital presentation, and significant microvascular disease may converge to produce extensive digestive necrosis. Recognition of underlying vascular pathology is crucial in the evaluation of complex abdominal trauma, given its potential impact on disease evolution and prognosis.