Source (Faculty of Medicine University of Belgrade)

Fig 1: Abnormally distended stomach.
Fig 2 and 3: The patient’s body was poorly nourished with body mass of only 21 kg (BMI 8,6 kg/m²)

A 22-year-old female was found dead in her bedroom bed. According to heteroanamnestic data, she had suffered from anorexia nervosa for five years. That day, according to her mother’s statement, she had a meal for the first time in two days. She rapidly consumed porridge (approximately 400 ml) and one apple and she drank about 600 ml of tea. A few minutes later (without history of any symptoms) the woman lost consciousness and died. The autopsy was performed two days later.

The deceased was extremely underweight – she weighed only 23 kg and was 161 cm tall (BMI 8.9 kg/m2) (Figure 3). There were no signs of external or internal injuries. The abdomen was not distended. Upon opening the abdominal cavity, extremely dilated stomach was noted (Figure 2). It completely filled the abdominal and partially the pelvic cavity (extending from the xiphoid to the bladder). Its vertical diameter was around 40 cm, while its horizontal diameter amounted to around 30 cm. When the stomach was opened, it revealed around 1.2 l of undigested content. The gastric wall was of usual color, without necrosis. The gallbladder was highly distended. The intestines contained a small amount of semisolid fecal content. There were no obstructions, ascites, peritonitis or depositions of fibrin in the digestive tract. The diaphragm was not elevated. All organs were small in size, yet without obvious signs of dehydration.

Toxicological testing was negative for alcohol and drugs. Biochemical findings showed vitreous chloride, sodium and potassium in the following concentrations: 78 mmol/l, 116 mmol/l and 9.86 mmol/l, respectively. The vitreous glucose, and urea levels were 4.1 mmol/l and 28 mmol/l, respectively; no ketones were found.

Finally, the underlying cause of death was AN, and the possible mechanism of death could have been a disruption of heart rhythm due to an electrolyte imbalance or vagal activation related to gastric dilatation.