J O U R N A L O F

CLINICAL
FORENSIC
MEDICINE
Journal of Clinical Forensic Medicine 13 (2006) 271273
www.elsevier.com/locate/jcfm

Case report

Haemorrhagic complication of acute necrotizing pancreatitis

presenting with sudden death
Marco Di Paolo *, Ilaria Marradi
Institute of Legal Medicine, University of Pisa, S. Chiara Hospital, Via Roma 55, 56126 Pisa, Italy

Accepted 9 November 2005

Available online 3 April 2006

Abstract

Certain complications of acute pancreatitis may lead to death, and of these, haemorrhage caused by rupture of a peri-pancreatic vessel
is among the most dangerous. The case reported here was remarkable because the onset of acute necrotizing pancreatitis was completely
asymptomatic and the severe haemorrhage of the portal vein that caused the patients death was only discovered at autopsy. The onset of
abdominal pain was immediately followed by death.
 2005 Elsevier Ltd and AFP. All rights reserved.

Keywords: Sudden death; Rupture of portal vein; Acute necrotizing pancreatitis; Complications; Asymptomatic pancreatitis

1. Introduction scribed an injection of antispastic (Buscopan). The symp-

Acute pancreatitis may have haemorrhagic complica-
tions, usually due to erosion of major pancreatic or peri-
pancreatic vessels, with massive bleeding into the
gastrointestinal tract or abdominal cavity. Though infre-
quent, these complications are the main cause of death in
more than 50% of fatal cases of acute pancreatitis.13 The
incidence of bleeding is much higher in necrotizing than
in interstitial pancreatitis (13.5% vs. 1.5%).4
Here we report an atypical presentation of acute pancre-
atitis, represented by sudden death due to hemorrhage of
the portal vein. The case is discussed in relation to the lit-
erature on this complication.
2. Case report
The subject was a 70-year-old male of Caucasian race,
suering from hypertension and enlarged prostate. In the
early hours of the morning he phoned the rst-aid station
complaining of periumbilical abdominal pain and was pre-
*
Corresponding author. Tel.: +39 50 2218510; fax: +39 50 560677.
E-mail address: marcodipaolo@med.unipi.it (M.D. Paolo).
toms were not considered suciently serious to warrant a
home visit. The injection failed to alleviate symptoms.
One hour later the pain increased in intensity and the
patient lost consciousness. He was at once taken to the
Emergency Unit of the nearby hospital by ambulance but
died on the way.
A forensic autopsy was ordered to shed light on the
cause of death and on why the doctor contacted at the rst
aid station had failed to intervene. The autopsy, conducted
at the Institute of Forensic Medicine, University of Pisa,
revealed massive intraperitoneal bleeding and many blood
clots; the largest clot was adjacent the hepatic hilus. Five
centimetres from the hilus, the portal vein had ruptured.
The top of the pancreas was obscured by clotted blood
and was enlarged; its parenchyma was haemorrhagic and
of remarkably reduced consistency. Retroperitoneal hem-
orrhagic inltration was also observed. Another nding
was mild coronary disease. Bile calculi were absent.
Histological examination of the portal vein lesion
showed abundant intramural haemorrhagic inltration,
especially externally, to the extent that the tunica was atro-
phied in places due to inltration. Inltration was progres-
sively less intense from the outside in, though interruptions

1353-1131/$ - see front matter  2005 Elsevier Ltd and AFP. All rights reserved.
doi:10.1016/j.jcfm.2005.11.008
272 M.D. Paolo, I. Marradi / Journal of Clinical Forensic Medicine 13 (2006) 271273
Fig. 1. Portal vein showing morphological dierences between normal
(above) and ruptured wall (below) (HE, 10).
of the external elastic lamina of the endothelium were
detected. Acute erosion of the portal vein wall with severe
haemorrhagic inltration (Fig. 1) was the nding.
Histological examination of the pancreas showed scat-
tered haemorrhagic pools in stroma characterised by dense
granular structures in many optically empty areas, compat-
ible with necrosis of adipose tissue due to acute haemor-
rhagic pancreatitis.
3. Discussion
The clinical manifestations of acute pancreatitis are so
varied that it should be considered in the dierential diag-
nosis of all upper abdominal pain.5 Though the major
symptom, abdominal pain may vary widely in intensity
from the typical sharp incapacitating pain to mild bearable
pain with more or less asymptomatic onset. Several cases in
which diagnosis was not made until autopsy have been
reported.6,7
If pancreatitis is mild, it often manifests exclusively
through a complication.8 There are many reports in the lit-
erature of cases of pancreatitis with local or other compli-
cations as initial symptom. Haemorrhage from major
vessels is not a rare complication. In the literature, it is esti-
mated to occur in 1.214.5% of cases, and was related to
severity of disease as long ago as the 1950s.9 However,
massive hemorrhage due to vascular damage is more fre-
quent in patients with chronic pancreatitis. When these
patients suer an episode of acute pancreatitis, a slight
increase in mortality is observed.10
Bleeding may be promoted by proteolytic and lipolytic
enzymes disseminated by the damaged pancreas. These
substances attack contiguous vessels causing elastolytic
erosion, which may lead to rupture. Frequent reports of
haemorrhage associated with post-acute pancreatitis have
usually involved rupture of pseudo-aneurysms.11 Other
mechanisms of bleeding include compression by pseudo-
cysts12 or pancreatic abscess13 A recent review of bleed-
ing-related cases reported in the literature records six epi-
sodes of rupture of the portal vein, three of which were
fatal.2
4. Conclusions
The haemorrhagic complication (rupture of the portal
vein) of the present case occurred in a patient with almost
asymptomatic pancreatitis. Symptoms appeared just before
lethal bleeding, too late to even hazard a diagnosis.
During the silent phase, the necrotic process underway
in the pancreas and the ensuing release of enzymes prob-
ably broke down the external layer of the portal vein
wall. Vascular erosion was presumably due to the eect
of pancreatic enzymes. We did not observe any signs
of intravascular thrombosis, a frequent nding in portal
rupture. Only one case of death soon after admission
to hospital, due to bleeding from a ruptured splenic vein,
has been reported.14
In conclusion, our case conrms previous assertions
about the necessity to add massive intraperitoneal venous
bleeding to the list of dierential diagnoses for sudden dete-
rioration in patients with acute pancreatitis.15 In our case,
the presenting symptom of acute pancreatitis unfortunately
coincided with that of the fatal complication. The patient
died only two hours after onset of symptoms that were
mild in the rst hour. There was not even sucient time
to take the patient to hospital.
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