What could cause 15 liters of blood in the stomach, as found during a postmortem examination, in a patient with potential underlying conditions such as liver cirrhosis, peptic ulcer disease, or previous gastrointestinal surgeries?

Postmortem Finding of 15 Liters of Blood in Stomach

In a postmortem examination revealing 15 liters of blood in the stomach, the most likely causes are massive variceal hemorrhage from portal hypertension (particularly esophageal or gastric varices in cirrhotic patients) or catastrophic peptic ulcer bleeding with arterial involvement, with varices being the leading cause of such massive hemorrhage. 1, 2, 3

Primary Causes of Massive Gastric Blood Accumulation

Variceal Hemorrhage (Most Common)

• Esophageal and gastric varices account for approximately 66-70% of massive hematemesis cases, particularly in patients with underlying liver disease and portal hypertension 3
• Varices develop when portal pressure exceeds 10 mmHg, with yearly hemorrhage rates of 5-15% and mortality of at least 20% at 6 weeks 3
• Fundic varices are a commonly overlooked source of massive bleeding and are associated with cirrhosis and portal hypertension 2
• The volume of 15 liters suggests either prolonged bleeding before death or catastrophic rupture with rapid exsanguination 1

Peptic Ulcer Disease with Arterial Involvement

• Peptic ulcer disease represents approximately 50% of nonvariceal upper GI bleeding cases and 17.5% of all upper GI bleeding 3
• Posterior duodenal wall ulcers can erode into the gastroduodenal artery, causing massive hemorrhage 4
• Gastric ulcers on the lesser curvature can erode into the left gastric artery 2
• Cameron's erosions in large hiatal hernias are a commonly overlooked cause that can lead to significant bleeding 2

Rare but Catastrophic Causes

• Dieulafoy's lesion, characterized by a large caliber artery in the stomach wall, accounts for only 1-2% of acute upper GI bleeding but can cause massive hemorrhage 2, 3
• Gastroduodenal artery pseudoaneurysm in patients with previous gastric surgery can present with massive bleeding and up to 90% mortality 4
• Aortoenteric fistula in patients with prior abdominal aortic aneurysm repair can cause catastrophic bleeding 2
• Gastric antral vascular ectasia, particularly in patients with chronic kidney disease and cirrhosis 2

Key Postmortem Diagnostic Considerations

Evidence of Underlying Liver Disease

• Look for stigmata of cirrhosis: jaundice, ascites, splenomegaly, collateral circulation of abdominal vessels, spider angiomas 1
• Decompensated liver cirrhosis and hepatic failure are the most common underlying diseases in patients with massive gastric bleeding, accounting for 8/13 deaths in one series 5
• Portal hypertensive gastropathy can contribute to diffuse bleeding 5

Medication and Risk Factor History

• NSAID use is a critical risk factor for peptic ulcer disease and NSAID-induced ulcers 2, 3
• Antiplatelet agents or anticoagulants significantly increase bleeding risk 3
• Helicobacter pylori infection is associated with peptic ulcer disease 1, 2

Anatomical Considerations

• Previous gastrointestinal surgery (gastrectomy, bypass, pancreatectomy) raises suspicion for pseudoaneurysm or marginal ulcer 4
• Lesions in the gastric body are most commonly missed during endoscopic evaluation and may be identified postmortem 5
• Examine blind areas: high lesser curve, under incisura angularis, posterior duodenal bulb, and esophagocardiac junction 2, 5

Pathophysiological Context

Blood Volume and Timing

• The human body contains approximately 5 liters of total blood volume 1
• 15 liters represents three times the total blood volume, indicating either:
  • Prolonged bleeding with continued gastric secretion and blood accumulation before death
  • Catastrophic arterial hemorrhage with rapid exsanguination
  • Postmortem blood accumulation from continued passive bleeding 1

Bleeding Patterns

• Active arterial bleeding (spurting) suggests ulcer erosion into a major vessel 4
• Diffuse mucosal bleeding patterns suggest hemorrhagic gastritis, often seen in acid-corrosive injury or severe stress 6, 5
• Blood exposed to gastric acid appears black or coffee-ground in appearance 3

Common Pitfalls in Postmortem Evaluation

• Do not overlook previous surgical history, as gastroduodenal artery pseudoaneurysm can remain asymptomatic for years before catastrophic bleeding 4
• Excessive blood in the stomach can obscure the actual bleeding site in 60/64 cases during endoscopic evaluation, making postmortem identification challenging 5
• Elderly patients (>65 years) are more prone to vascular lesions, which account for up to 40% of causes in patients over 40 years old 2, 3
• Patients with significant comorbidities (cardiovascular, renal, or liver disease) have higher mortality rates 2, 3