Tsokos M, Türk E E
Institute of Legal Medicine, University of Hamburg, Germany.
Arch Pathol Lab Med. 2002 Oct;126(10):1197-200. doi: 10.5858/2002-126-1197-EVHPAS.
Some autopsy studies have dealt with histologic features of esophageal varices after different therapeutic procedures. However, to the best of our knowledge, no reports have been published describing outpatient characteristics that are associated with fatal esophageal variceal hemorrhage in a medicolegal autopsy population.
To (1) assess the incidence of sudden deaths from esophageal variceal hemorrhage in an unselected medicolegal autopsy population and (2) determine demographics of outpatients dying from esophageal variceal hemorrhage with special reference to blood alcohol concentrations at the time of death.
We performed a retrospective study of all autopsy cases of sudden death from esophageal variceal hemorrhage from a total of 6038 medicolegal autopsies performed over a 5-year period (1997-2001). We analyzed individual cases to determine gender, age, location and histology of bleeding esophageal varices, pathogenic mechanism for esophageal varices, concomitant underlying diseases contributing to fatal outcome, body mass index, circumstances at the death scene, and blood alcohol levels at the time of death. We reviewed the results of toxicologic analyses of alcohol concentrations in samples of femoral venous blood and urine obtained at autopsy; concentrations had been determined by gas chromatography with mass spectroscopy and enzymatic assays.
We identified 45 cases of fatal esophageal variceal hemorrhage that occurred out of hospital and presented as sudden death; the corresponding 5-year incidence in this autopsy population was 0.75%. All of the deceased were white; the male-female ratio was 1.6:1, and the mean age was 50.6 years. Ruptured esophageal varices were located in the lower third of the esophagus in 44 cases. Cirrhosis of the liver was present in all cases (alcoholic cirrhosis of the liver in 42 cases), and a hepatocellular carcinoma was present in 3 cases. Alcohol-induced pancreatic tissue alterations were frequently found. The results of toxicologic analysis were positive for alcohol in femoral venous blood and urine in 30 cases. Blood alcohol levels at the time of death were less than 100 mg/dL (21.7 mmol/L) in 15 cases, between 100 and 200 mg/dL (21.7 and 43.4 mmol/L) in 8 cases, and greater than 200 mg/dL (43.4 mmol/L) in the remaining 7 cases.
Apart from abnormalities in coagulation due to poor liver function in long-term alcohol users, acute alcohol intake may represent an important factor influencing mortality in individuals with esophageal variceal hemorrhage. Acute alcohol intake has transient effects on blood clotting time caused by ethanol and its main metabolites. In the present study, bloodstains at the death scene and unusual body positions of the deceased that aroused suspicion of a violent death were leading reasons for conducting a medicolegal autopsy. Apart from aspects of forensic pathology, the demographics of our study population are also noteworthy from the viewpoint of social medicine. The data we present stress the importance of fatal esophageal variceal hemorrhage as a relevant cause of sudden death occurring outside the hospital in socially isolated, alcohol-addicted individuals.
一些尸检研究涉及不同治疗程序后食管静脉曲张的组织学特征。然而，据我们所知，尚无报告描述在法医学尸检人群中与致命性食管静脉曲张出血相关的门诊患者特征。
（1）评估在未经选择的法医学尸检人群中因食管静脉曲张出血导致的猝死发生率；（2）确定因食管静脉曲张出血死亡的门诊患者的人口统计学特征，特别参考死亡时的血液酒精浓度。
我们对1997年至2001年这5年间进行的6038例法医学尸检中所有因食管静脉曲张出血导致猝死的尸检病例进行了回顾性研究。我们分析了各个病例，以确定出血性食管静脉曲张的性别、年龄、位置和组织学、食管静脉曲张的致病机制、导致致命结局的伴随基础疾病、体重指数、死亡现场情况以及死亡时的血液酒精水平。我们回顾了尸检时采集的股静脉血和尿液样本中酒精浓度的毒理学分析结果；浓度通过气相色谱 - 质谱联用和酶法测定。
我们确定了45例发生在院外并表现为猝死的致命性食管静脉曲张出血病例；该尸检人群中相应的5年发生率为0.75%。所有死者均为白人；男女比例为1.6:1，平均年龄为50.6岁。44例破裂的食管静脉曲张位于食管下三分之一处。所有病例均存在肝硬化（42例为酒精性肝硬化），3例存在肝细胞癌。经常发现酒精引起的胰腺组织改变。30例股静脉血和尿液的毒理学分析结果显示酒精呈阳性。15例死亡时的血液酒精水平低于100mg/dL（21.7mmol/L），8例在100至200mg/dL（21.7至43.4mmol/L）之间，其余7例大于200mg/dL（43.4mmol/L）。
除了长期饮酒者因肝功能不佳导致的凝血异常外，急性酒精摄入可能是影响食管静脉曲张出血患者死亡率的一个重要因素。急性酒精摄入对乙醇及其主要代谢产物引起的血液凝固时间有短暂影响。在本研究中，死亡现场的血迹和死者异常的体位引起了对暴力死亡的怀疑，这是进行法医学尸检的主要原因。除了法医病理学方面，从社会医学的角度来看，我们研究人群的人口统计学特征也值得关注。我们提供的数据强调了致命性食管静脉曲张出血作为社会孤立、酗酒个体在院外发生猝死的一个相关原因的重要性。
