We present here a case of gastric and bowel ischemia presenting to the forensic facilities without a prior diagnosis before the unexpected death.

Gross examination revealed a blackish and sharply discolored stomach and first tract of the jejunum, that oriented towards ischemia and infarction. Nevertheless, given the typically redundant blood flow to the stomach [9] initial consideration was given to putrefaction changes as the cause of discoloration, since they are known to act as confounding factors for the diagnosis of bowel ischemia [3]. Despite the relatively long post-mortem interval of our case, other distal intestinal loops appeared regularly pinkish, so a significant influence of post-mortem decay was ruled out.

Histologically, despite marked autolytic changes, signs of gastric and intestinal ischemia/infarction were still detected, including the presence of neutrophils in the mucosa and the small parietal vessels. The duodenojejunal flexure showed diffuse erythrocyte extravasation and small non-occlusive thrombi within the submucosal vessels. Both macroscopic and microscopic findings were thus consistent with gastrointestinal ischemia/infarction.

The symptoms and signs exhibited by the patient, including abdominal pain and distension, vomiting, diarrhea and anemia, also corresponded to the clinical picture of ischemia affecting the stomach or bowel, albeit non-specific [9, 11, 27].

Regarding the cause of gastric and bowel ischemia, as already stated, bowel ischemia is commonly classified as occlusive mesenteric and non-occlusive [28]. In our case, the autopsy revealed an occlusion of the celiac trunk, which is a plausible cause of ischemia [29]. However, the clinical data reviewed for the investigation proved fundamental in assessing that this blockage to the blood flow had occurred several years prior and could not therefore be responsible for the acute ischemia.

Although multiple CTs showed revascularization of the stomach by collateral vessels, the reviewed health care data also revealed an unusual and rather precarious vascularization pattern of the stomach. In this peculiar context of collateral revascularization due to occlusion of the celiac trunk, the SMA might have provided a partial blood supply to the stomach. However, the occlusion of the SMA would have resulted in a more extensive necrosis, also affecting other vascularized intestinal tracts, such as the small intestine, the right and transverse large bowel [30]. Instead, the ischemia/infarction was limited to the stomach and the first tract of the small bowel.

The non-occlusive type of bowel ischemia seemed more plausible also due to the fact that the SMA was not completely occluded, showing focal areas fibrin strands and neutrophils.

In the non-occlusive AMI, intestinal necrosis is caused by local vasoconstriction in a condition of abdominal hypovolemia, reduced cardiac function, or vasoconstrictor medications [28]. Gastric ischemia has also been associated with non-occlusive causes, such as systemic hypoperfusion in shock, sepsis or severe atherosclerosis [8,9,10, 27, 31]. However, many cases remain idiopathic [27].

In the case here presented, the patient displayed compromised circulation in the usually rich vascular network of the stomach and this likely predisposed her to transient reductions in splanchnic circulation. She also presented advanced age, severe atherosclerosis, and hypertension, which are reported in the literature as risk factors for gastric ischemia [32].

No other causes of systemic hypoperfusion were identified, such as third space losses and systemic inflammatory response syndrome (SIRS) or SIRS-multiple organ dysfunction syndrome (MODS). Particularly, no diffuse alveolar damage, histopathological markers of acute respiratory distress syndrome (ARDS), reduced coronary perfusion or increased inflammatory mediators in the organs were found [33]. However, microbiological analyses were not performed.

The acute tubular necrosis, cortical thinning and blurred cortico-medullary junction were considered indicative of chronic kidney disease, given the patient’s history and age. Nevertheless, the pre-existing conditions, including COPD, heart and kidney failure, likely compromised the woman’s ability to withstand the acute gastric ischemia.

The multiple episodes of vomit and diarrhea might have exacerbated dehydration and hypovolemia and might have led to further hypoperfusion. The disruption of the delicate balance of circulatory compensation might have resulted in gastro-intestinal ischemia/infarct.

Since no mechanical obstruction, perforation, or peritonitis were found, and occlusive thrombosis of the SMA was absent, the ischemia was classified as non-occlusive and a likely result of a systemic disequilibrium.

Intestinal ischemia carries a high mortality rate of 60–80%, as the alteration of the mucosal barrier triggers cytokine and reactive oxygen species (ROS) release. These molecules cause damage to the microcirculation and facilitate bacterial migration, leading to subsequent reperfusion injuries due to neutrophil chemotaxis and ROS production [28]. Gastric ischemia has an estimated mortality rate of 30–40% [27].

Given the rarity of the condition, the non-specific symptoms, the compromised health status of the patient, and the very high mortality rate, no medical liability could be proven with scientific evidence. On the other hand, the case here presented highlights that gastric ischemia could be encountered both in the clinical scenario, where the level of suspicion should be very high, and in the post-mortem context.

Given that the autopsy might remain the only opportunity to achieve a diagnosis, it is strongly suggested to gather comprehensive medical history data to avoid misinterpretations, and to document all relevant associated comorbidities.

The forensic pathologist should consider the possibility of gastric ischemia, particularly when examining older people with a history of hypertension, atherosclerosis, previous aortic surgery, and impairment of the gastric supply, as well as other causes for hypovolemia. This is especially crucial for older women, who are estimated to spend almost 12 years in ill health [5].

Considering the very high prevalence of cardiovascular diseases in the aging population, especially among women, and the variations in morbidity and mortality by age in older women, forensic pathologists should be aware of the possibility of encountering previously uncommon conditions, as in the case presented.