Autopsy

From patholines.org
Jump to navigation Jump to search

Author: Mikael Häggström [notes 1]

Comprehensiveness

Factors supporting a relatively more comprehensive autopsy and/or report, particularly in the inclusion of negated findings:

  • Lack of explanation from existing evidence. On the other hand, for example, upon finding an obvious aortic rupture, the rest of the autopsy is less relevant and may be relatively short.
  • Double-reading: If your report is likely to undergo double reading by another pathologist before sign-out, it needs to be more detailed, because the doctor who will do the double-reading then knows that you have looked at those locations.
  • Highly suspected locations, such as given from the referral.

In this page, the following signs and text coloring are used for comprehensiveness:

  • Minimal depth
  • (Moderate depth)
  • ((Comprehensive))

Basic checklist of non-forensic autopsy

There are many variants, with the following being a suggestion:

Heart

edit

  • Remove the parietal pericardium
  • Separate the heart from the from lungs by cutting through the major vessels
  • Dissect the coronary vessels
  • On the right side of the heart, dissect in the direction of blood flow: Superior vena cava > right atrium > tricuspid valve > right ventricle. Look for thromboses or patent foramen ovale.
  • Dissect the atrial appendages, to exclude thromboses.
  • Dissect the left ventricle, such as into circumferential slices from the apex to the base.[notes 2] Inspect (and measure) the left ventricular wall thickness.

Look for signs of myocardial infarction. Further information: Heart autopsy and Autopsy of myocardial infarction

Other thorax

  • Dissect the aorta, with an anterior approach to the aortic arch and major branches, and posterior approach to the descending thoracic aorta. Check for thrombosis and degree of atherosclerosis. Then separate the descending thoracic aorta from the esophagus.
Relations of the aorta, trachea, esophagus and other heart structures
  • Dissect the pulmonary arterial system, from the pulmonary trunk and including at least segmental arteries. To avoid cutting through the left main bronchus (passing anteriorly to the left main pulmonary artery), the initial dissection of the left main pulmonary artery may begin from an anterior perspective but keeping the cuts along the posterior wall, until the dissection can be seen and be continued from a posterior approach. Check the pulmonary arteries for thrombosis.
  • Esophagus: Distinguish from trachea and dissect
Blood clots[1]
Pre-mortem Post-mortem
Tumor embolus in the main pulmonary artery.jpg
Texture Dull Shiny
Wall adherence Yes No
Color Grey. Possibly zebraic appearance by lines of Zahn, with mixed red and grey/yellow Dark purple or bilayered yellow/red (by gravity sedimentation)
Pressurized Yes, can eject from lumen No, needs to be pulled-out
Consistency Firm and brittle Elastic, jellylike
  • Dissect the trachea and the bronchial tree, at least to segmental bronchi. Check for obstructions.
  • Make some additional sections through the lung parenchyma. Squeeze at each side to detect any pus and edema.[2] Further information: Lung autopsy.
  • Cut each thyroid lobe in horizontal slices and inspect the parenchyma.
  • Look for enlarged lymph nodes in the hilar and paratracheal area.

Retroperitoneal

For orientation, the coeliac trunk and mesenteric arteries exit the aorta from the anterior side.

  • Dissect the descending abdominal aorta. Cut external iliac artery from a dorsal approach, or after freeing ureters.[notes 3]
  • Dissect the renal arteries until entry into kidneys
  • Make a couple of cuts through the adrenal glands, such as transversal ones, and look mainly for tumors.
  • Cut the kidneys in the coronal planes. Further information: Kidney autopsy.
  • Dissect the ureters to the bladder.
  • Dissect the prostate and urinary bladder by an anterior approach. Dissect the ureteropelvic junctions.
  • Dissect the rectum

Peritoneal

  • Remove the diaphragm and excess omentum
  • Dissect the ventricle along the greater curvature, as well as the duodenum and the esophageal entry into the ventricle
  • Dissect the extrahepatic biliary tract: Identify the ampulla of Vater, possibly by bile flow when squeezing the gallbladder. Dissect the common bile duct, cystic duct and gallbladder.[notes 4]
Further information: Gallbladder
  • Make consecutive liver slices, such as in the sagittal or coronal plane.
Further information: Liver
"Long" and "short" axis.[3]
  • Make consecutive short axis slices through the spleen and pancreas[notes 5].

Brain

edit

  • Inspect: Grooves indicating herniation? Hemorrhages?
  • Dissect the basilar artery and circle of Willis, either before or after separation from the brain.[notes 6] Look mainly for thromboses.
  • Separate the brainstem, cerebellum and cerebrum, which may be done by first separating the former two together from the cerebrum. Slice each part, looking for hemorrhages and/or infarcts.

Demonstration

Consider summoning involved clinicians for a demonstration of any findings.

Weighing

Separate and weigh these organs:

Tissue sampling

Any tissues where histopathology may aid in establishing the cause of death. If there is no clear cause of death macroscopically after an autopsy, take routine samples:

  • Heart
  • (Each lobe of) each lung
  • Liver
  • Each kidney

Reporting of non-forensic autopsy

The order of the sections may vary. Annotations used in this example
[4]
Legend

<< Decision needed between alternatives separated by / signs >>
{{Common findings / In case of findings}}
[[Comments]]
Organs or important regions are in bold in this example for clarity, but does not need to be in an actual report.
In this page, the following signs and text coloring are used for comprehensiveness:

  • Minimal depth
  • (Moderate depth)
  • ((Comprehensive))
Data
  • Autopsy No.: ________
  • (Hospital No.:000046)
  • Patient name: Bloggs, Joe
  • (Patient No.:)
  • (Ward :_______)
  • Age [[or birthdate]]: _____
  • (Sex: ______)
  • (Race: ______)
  • (Permission: From [[usually close relative of the patient]])
  • Date (and time) of death: ______
  • Date (and time) of autopsy: ______
  • (Date of report: _________)
  • Attending physician: _______
  • (Prosector:__________)
  • {{Limitation of the autopsy}} [[such as restriction to thorax only]].
Final autopsy diagnosis / Preliminary diagnoses

[[May be preliminary if histopathology samples are taken.]]

  • [[First, generally the final cause of death, such as:]]
  • {{Acute circulatory failure with pulmonary edema and congestion of abdominal organs.}}
  • [[Other diagnoses that may have caused the death is listed in causative order:]]
  • {{Acute myocardial infarction.}}
  • {{Severe arteriosclerosis.}}
  • [[Other autopsy diagnoses, including presumably incidental ones:]]
  • {{Hepatic steatosis.}}
  • [[Clinically known diagnoses may be marked as such:]]
  • {{Type 2 diabetes (clinical diagnosis).}}
(Clinical history

_________)

(Laboratory data

_________)

External inspection

((The autopsy is performed approximately __ hours after death.)) The body is a ((well developed,)) << ((well nourished)) / {{underweight / overweight}}>> (__ year old) [[if not already given in data]]) << woman / man >>. Lengths is __ cm and weight is __ kg.

Usual signs of death. (Rigor mortis is << well marked / broken >>. Lividity is seen on the << front / back and/or side >>.)

(On the torso there are no puncture marks or healed surgical scars.)((There is no jaundice or peripheral edema. The head is not deformed. The sclerae, cornea and lenses are clear. The nose and external ears are unremarkable and their passages are clear. The lips and gums show no lesions and the patient is not edentulous. The neck structures are symmetrical, and there are no unusual masses. The thorax has normal contour and symmetry. [[In females:]] breasts and nipples are unremarkable. External abdominal palpation detects no abnormal masses or fluid waves. The extremities show no scars or deformities. No palpable inguinal masses. [[In males:]] The testes are descended and without abnormal masses.))

Internal examination

((Standard thoracic incisions are employed.))
{{Overall severe autolysis, making pathologic assessment difficult.}}
((The subcutaneous fat measures ___ in thickness at the thorax. The skeletal muscles are red-brown, normally firm and of normal bulk. There is no subcutaneous emphysema.))

Serous cavities

No increased amount of fluid in the pericardial, pleural or abdominal cavities. Serous surfaces are smooth and lustrous.((No signs of inflammation. No adhesions.))

Circulatory system

edit
The heart << has normal weight / is enlarged [[ > 399 g in women and> 449 g in men]] >>, weighing ___ g.

Normal configuration (No atrial or ventricular dilation. No ventricular wall thickening) / {{The left ventricle has {{concentric}} hypertrophy, with a wall thickness of ___ mm.}} ((No atrial or ventricular dilation. The left ventricular wall thickness is __ cm and the right is ___

(Foramen ovale is closed.) ((The ductus arteriosus is obliterated))
The coronary arteries ((arise in normal position. They)) have << no / mild / moderate / severe >> {{and particually calcified}} arteriosclerosis, without significant constrictions. No thrombi in the cardiac atria (including auricles), chambers or coronary arteries.

Cordae tendineae, the endocardium and heart valves are unremarkable. (The endocardium is smooth and shiny. Cordae tendineae are unremarkable. The valves are normal in number, and are thin and fine at the openings.) ((The endocardium is smooth, transparent and free of mural thrombi. The valve leaflets and chordae tendinae are overall delicate, pliable and free of lesion or calcification. No signs of inflammation.
The valve ring circumference are: Tricuspid and mitral approximately ___ cm and aortic and pulmonic approximately ___ cm.
The epicardium and subepicardium are unremarkable.))

The myocardium has ((a homogeneous reddish brown color, and)) no signs of fresh lesion (or scar). In the aorta (and its major branches) there is {{widespread}} << no / mild / moderate / severe >> arteriosclerosis. No aneurysm. (Renal arteries have no significant stenosis.) No thrombus in (vena cava, ) the pulmonary arteries ((or the pulmonary veins)).

Respiratory system
The larynx, trachea and bronchi are normally configured, with non-irritated lining. ((Larynx has normal configuration. The vocal cords are smooth and symmetrical. The trachea and the larger bronchi have non-irritated lining. No ulceration.)) {{The bronchial lumina contain small amounts of frothy mucoid material.}}

No foreign content((, dilatation or mucosal change)). ((Normal lobar structure. No tumor. No visible signs of inflammation.))
The lungs ((have the usual shape and lobar divisions, and)) have << normal / increased >> weight, of __ g on the right and ___ g on the left. (The consistency is normal) {{/ abnormally firm.}}Cut Surfaces are unremarkably dark red, with no definable tumors( or bleeding).
{{Watery and frothy liquid is pressed from the parenchyma, indicating pulmonary edema.}}
(The rib cage is intact) / {{Multiple rib fractures, consistent with CPR.}}

Digestive system

((The tongue has no bleeding.))

The esophagus, stomach and intestines are ordinarily configured, without tumors or blood in the lumen. ((The esophageal mucosa has normal thickness and no irritation. No diverticula or varices.
The ventricle is of normal size, with normal content. Its << mucosa shows no signs of lesions))
/ {{mild / moderate erosions, but no ulceration}}.
((The duodenum, jejunum and ileum and colon are ordinarily configured with non-irritated lining. Content is normal. No visible tumor.)) (The appendix is non-irritated and of normal size.)[notes 4]

{{Colonic diverticula without inflammation or perforation.}}

The liver weighs ___g. The liver is << of normal size / {{enlarged}}, at ___g. [[</nowiki>Men: 970-1860 g.[5] Women 600-1770g.[6].<nowiki>]]

The surface is smooth. << Normal/ {{/ firm}} consistency. Cut surface is normal / << {{Moderate-begin]]shows normal homogeneous brown parenchyma) / {{Yellowish color, indicating steatosis}} / {{dark nutmeg similar paths, indicating congestion}}. (No focal changes.) The gallbladder has (regular size,) thin walls and contains {{__ [[number of]] gallstones measuring up to __ mm. Otherwise}} normal bile. ((No tumor or gallstones.)) {{Mild / Moderate / Severe cholesterolosis.}} edit The (extrahepatic) bile ducts are open(, ordinary and without gallstones in the lumen).
The pancreas has normal size (and shape). Cut surfaces are normal(( without bleeding or definable focal changes)).

Lymphoid and endocrine organs

The spleen is of << normal size {{ / Enlarged [[> 230g]]}}>>, at ___ g. Normal consistency / {{ Firm consistency indicating of chronic venous stasis}}. Cut surfaces have normal appearance / ( normal bluish-red color, with no definable focal changes).
The thyroid and adrenal glands are normal bilaterally / (are ordinarily configured and with no definable focal changes on cut surfaces).

No abnormal lymph nodes. ( Lymph nodes in para-tracheal, para-aortic and abdominal regions are of normal size, texture and color.)
((No definable focal changes on cut surfaces.))
Urogenital

edit The kidneys are equally sized / (of normal size, with a total weight of ___ g)((a weight of ___ g on the right side and ___ g on the right)).

Sex Weight, reference range[notes 7]
Right kidney Left kidney Total
Men[7] 80–160 g (2.8–5.6 oz) 80–175 g (2.8–6.2 oz) 160-335g (5.6-12.8 oz)
Women[8] 40–175 g (1.4–6.2 oz) 35–190 g (1.2–6.7 oz) 75-365g (2.6-12.9 oz)


(No abnormal adhesions between the kidneys and surrounding fibrous capsules.)
The kidneys have smooth surfaces/ {{Granular surface, possibly indicating nephrosclerosis}}. Cut surfaces have well-defined medulla, cortex, and papillae.
The renal pelvis and ureters are unremarkable /( Renal pelvis and ureters have normal calibers, with non-irritated mucosal surfaces and open lumens).
The bladder is unremarkable / ( is of normal size, with normal mucosa. No tumor).
[[Either:]]

  • [[Male]]: The prostate is of normal size ((and has normal color and elastic consistency and color)). (No definable focal changes on cut surfaces.)
  • [[Female]]: Uterus and adnexa are unremarkable.[notes 4]
Central nervous system

edit

The meninges and venous sinuses are unremarkable. ((The dura and venous sinuses are unremarkable. The leptomeninges are thin, shiny and non-irritated, with no visible bleeding.

(No visible thrombi. No subdural hematoma.)

The brain is symmetrical and weighs ___g. ( The cerebral and cerebellar hemispheres are of equal size, and have a normal weight of ___g. [[Men: 1.180 to 1.620 g. Women: 1.030 to 1.400 g]][9][10]
No signs of herniation (No grooves on the bases of the cerebrum or cerebellum.)

((The cerebral ventricles are of normal size, with normal linings.)) Cut surfaces of the cerebrum, cerebellum and brainstem show (normal gray and white parenchyma, and) no ((encephalomalacia, ))(hemorrhages, tumors or other) focal abnormalities.
The basal cerebral arteries << are ordinary / {{have mild / moderate / severe atherosclerosis}}>> without aneurysms or thrombus.

Skeleton

Scalp and base of skull are ordinary / (without visible lesions or injuries).
((The vertebral column is unremarkable.))

Histopathology

No samples taken / {{Tissue samples have been taken from the << heart, lungs, liver and/or kidneys >> for supplementary microscopic and/or bacteriological examination.}}

((Clinicopathologic correlation))

[[Discussion of how findings relate to the probable clinical course.]]

See also: General notes on reporting

Notes

  1. For a full list of contributors, see article history. Creators of images are attributed at the image description pages, seen by clicking on the images. See Patholines:Authorship for details.
  2. An alternative approach is to cut the left ventricle through a cut along the left lateral margin, followed by an anterior cut from the apex to the aortic root, freeing the anterior wall. Then cut through the plane of the myocardium of the anterior and posterior myocardial wall, as well as the septum, for any signs of infarction. (Dissect one or more papillary muscles for infarction.)
  3. Measures are taken to avoid cutting through the ureters.
  4. 4.0 4.1 4.2 An appearance like after extirpation such as cholecystectomy, hysterectomy (with bilateral salpingo-oophorectomy) and/or appendectomy, may be reported as "Appearance like after ___". An attempt should be made to confirm it from available medical records.
  5. The pancreas may also be cut in the longitudinal plane.
  6. The arteries of the skull base are preferably dissected after separation from the brain if there is a need to demonstrate the case.
  7. Renal weight range is the standard reference range, that is, defined as the interval between which 95% of values of a reference population fall into.

References

  1. Michael Bonert. Autopsy. Page was last modified: 6 September 2016
  2. Burton, Julian L.; Rutty, Guy N. (2010). The Hospital Autopsy A Manual of Fundamental Autopsy Practice (3rd ed.). Oxford University Press. ISBN 978-0340965146. 
  3. Pellerito, John; Polak, Joseph F. (2012). Introduction to Vascular Ultrasonography (6th ed.). Elsevier Health Sciences. p. 559. ISBN 978-1-4557-3766-6. 
  4. The report is partially inspired from: . Autopsy Report No. A97-015. State University of New York Health Science Center at Syracuse, Department of pathology (1997-05-26).
  5. Standard reference range: Molina, D. Kimberley; DiMaio, Vincent J.M. (2012). "Normal Organ Weights in Men ". The American Journal of Forensic Medicine and Pathology 33 (4): 368–372. doi:10.1097/PAF.0b013e31823d29ad. ISSN 0195-7910. 
  6. Standard reference range: Molina, D. Kimberley; DiMaio, Vincent J. M. (2015). "Normal Organ Weights in Women ". The American Journal of Forensic Medicine and Pathology 36 (3): 182–187. doi:10.1097/PAF.0000000000000175. ISSN 0195-7910. 
  7. Standard reference range: Molina, D. Kimberley; DiMaio, Vincent J.M. (2012). "Normal Organ Weights in Men ". The American Journal of Forensic Medicine and Pathology 33 (4): 368–372. doi:10.1097/PAF.0b013e31823d29ad. ISSN 0195-7910. 
  8. Standard reference range: Molina, D. Kimberley; DiMaio, Vincent J. M. (2015). "Normal Organ Weights in Women ". The American Journal of Forensic Medicine and Pathology 36 (3): 182–187. doi:10.1097/PAF.0000000000000175. ISSN 0195-7910. 
  9. Standard reference range: Molina, D. Kimberley; DiMaio, Vincent J.M. (2012). "Normal Organ Weights in Men ". The American Journal of Forensic Medicine and Pathology 33 (4): 368–372. doi:10.1097/PAF.0b013e31823d29ad. ISSN 0195-7910. 
  10. Standard reference range: Molina, D. Kimberley; DiMaio, Vincent J. M. (2015). "Normal Organ Weights in Women ". The American Journal of Forensic Medicine and Pathology 36 (3): 182–187. doi:10.1097/PAF.0000000000000175. ISSN 0195-7910.