Introduction to Cellular and General Pathology - OAU Medical School 2021.pdf

Introduction to Morbid Anatomy

1. Introduction to Anatomical
Pathology
Dr. A.O. Komolafe
MBChB, FMCPath, Cert.FSHR

2. Outline
•Objectives
•Core definitions
•Components of Anatomic Pathology
•Cellular basis of diseases
•Cellular Injury
•Cell Death: Apoptosis and Necrosis
•Autopsy Pathology

3. Objectives
•Understand the concept of diseases
•Understand the cellular basis of diseases
•The role of the basic sciences in diseases
•The concept of Autopsy Pathology

4. What is Pathology?
•A Study of disease processes by scientific methods
•Major investigative armof modern medical science
•Pathology –Study of ‘suffering’

5. What is Pathology?
•Pathology (from Greek pathos, feeling, pain, suffering; and logos,
study of) is the study of the processes underlying disease and other
forms of illness, harmful abnormality, or dysfunction.
•Branch of medical science that studies the structural and functional
changes in cells, tissues and organs that underlie disease.
•Pathology as a field of knowledge forms the basis of the scientific
reasoning behind the practice of medicine.

6. What is Pathology?
•Pathology is a branch of medical science that involves the study and
diagnosis of diseases by the examination of surgically removed
organs, tissues (biopsy samples), various body fluids, and in some
cases the whole body (autopsy).
•Pathology arrives at diagnosis by examining gross anatomical make
up, appearance of the cells using immunological markers and
chemical signatures in the cells.
•Pathology is study of disease processes vis a vis the causes,
mechanisms and extent of disease

7. What is Disease?
A state in which there is a
disturbance of the normal
function of an organ, a part or the
whole of the body.
-A disruption of homeostasis

8. The Concept of Homeostasis
❑The maintenance of constancy of the internal environment
❑Effects caused by stress
❑Adaptation

9. Adaptation
•Cells encounter stress from internal
and external environmental changes
•Injury > failure of adaptive capacity
→death
•Failure of adaptation lays the basis for
disease development

10. What causes disease? (1)
•Pre-scientific concepts
1.Demons cause ill-health
2.Illnesses are punishments for
faults
3.Diseases are mystical

11. What causes disease? (2)
•The Hippocratic concept
➢ Man is made up of four ‘humours’-air, blood, bile
and fire
➢The humours exist in equal proportions in health
➢Disease is caused when the equilibrium between
these humours is disturbed

12. What causes disease? (3)
•The Origins of Pathology
•AnthoniBenivieni
-Published a book ‘De AbditisMorborumCausis’(The Hidden Causes
of Diseases) in 1507
•Rudolf Virchow(1821-1905)
-Propounded the theory of cellular pathology

13. Rudolf Virchow

14. Morgagni

15. Rokitansky

16. What Causes Disease? (4)
•Modern Times –The lesionalbasis of disease
✓Aetiology
✓Pathogenesis
✓Pathophysiology
The advent of molecular Pathology

17. Aspects of Disease
•Aetiology: basic cause
•Pathogenesis: sequence of events from
first injury to full disease expression
•Pathophysiology: dynamic mechanism of
functional alteration
•Morphology
•Functional Significance/Clinical
Correlation

18. Role of Pathology
Investigativeapproachtodisease
management
Pathology in hospital practice
Academic pathology
Translational pathology

19. Branches of Pathology
•Morbid Anatomy (Anatomical
Pathology)
•Chemical Pathology
•Medical Microbiology
•Haematology

20. What is Morbid Anatomy?
•Study of morphological alterations (altered structural
anatomical relationships at the macroscopic and
microscopic level) in tissues caused by disease
•Synonyms: Anatomical Pathology, Histopathology,
Pathological Anatomy

21. Materials and Methods
•Material: Tissues, scrappings, exfoliated cells,
aspirated cells
•Methods
1. Gross inspection
2. Light Microscopy
3. Electron Microscopy

22. Light Microscopy
•Routine Stains
Haematoxylin and Eosin
•Special Stains
Histochemistry
Immunohistochemistry (immunohistology)
In-situ Hybridization etc

23. Aspects of Morbid Anatomy in Clinical Practice
•Surgical Pathology: essential diagnosis,
prognostic information
•Intraoperative Consultation
•Cytopathology
•The Autopsy
quality control, education, medico-legal
reasons

24. Surgical Pathology
•All surgically resected materials must be subjected to
histological examination
•Biopsy pathology
Incisional biopsy
Excisional Biopsy
Frozen section diagnosis

25. Surgical Pathology
•Surgical Pathologyis the most significant and time consuming branch
of pathology with a primary focus on examining tissues with the
naked eye or under a microscope for definitive diagnosis of disease.
•Surgically removed specimens are received from sources such as
small biopsies of skin, core biopsies for the diagnosis of cancer, and
the operating room where tumours/new/abnormal growths are
removed.
•Surgical pathology involves macroscopic (gross) and microscopic
(histologic) tissue evaluation where the molecular properties of tissue
samples are assessed by immunohistochemistry or other laboratory
tests.

26. Surgical Pathology
•Representative histological sections of tissue are processed for
microscopic viewing using either chemical fixation or frozen section.
•Frozen section processing involves freezing the tissue and generating
thin frozen slices of the specimen which are mounted onto glass
slides. Prior to viewing the tissue under a microscope, slides
processed by chemical fixation or frozen section are either stained
with chemicals or antibodies to reveal/highlight cellular components.

27. Cytopathology
•Cytopathologyis a highly specialised branch of pathology that studies
and diagnoses diseases on the cellular level. It is usually used to aid in
the diagnosis (rapid diagnoses aid early treatment)of cancer, but also
helps in the diagnosis of certain infectious diseases and other
inflammatory conditions.
•Cytopathology is generally used on samples of free cells or tissue
fragments that spontaneously exfoliate or are removed from tissues
by abrasion or fine needle aspiration, in contrast to histopathology,
which studies whole tissues.

28. Molecular Pathology
•Molecular Pathologyis a relatively recent discipline that has achieved
remarkable progress over the past decade.
•It emphasizes the study and diagnosis of disease through the
examination of molecules within organs, tissues or bodily fluids.
•Many diseases such as cancer are caused by mutations or alterations
in the genetic code of a person, and identification of specific hallmark
mutations allows clinicians to classify a disease and choose the most
appropriate treatment.

29. Molecular Pathology
•Molecular analysis isleading the way towards personalized medicine
by allowing us to predict a patient’s response to certain anti-cancer
therapy based on their own genetic make-up.
•Molecular Pathology includes the development of molecular and
genetic approaches to the diagnosis and classification of human
tumours and also to design and validate predictive biomarkers for
prognosis of the disease, and susceptibility of developing certain
cancers in individuals.

30. Molecular Pathology
•The high levels of sensitivity provided by molecular
assays allows for the detection of very small tumours
that are otherwise undetectable by other means, and
will likely result in earlier diagnosis, improved patient
care and predictably better treatment outcomes for
survival.

31. Preservation of harvested organs
•Tissues are preserved in 10% buffered formal saline in ratio 1:10
(specimen to fixative). This is a general fixative.
•Specific fixatives such as Bouin’s fluid are used for testis,
glutaraldehyde for electron microscopy studies.

32. Excised breast mass 47 yr. F

33. Diffuse cellular infiltrates in breast lobules and
fat

34. Lipophages within breast fat

35. Giant cells ingesting fat debris

36. CELLULAR INJURY
The cell
▪The basic unit of life which is able to functionwhen
undivided, that is uncompromised in structure
▪Endowed with structures & functions for genetic
programs of metabolism, differentiation & specialization
▪Can handle physiologic demands maintaining a steady state
(homeostasis)

37. ▪Occurs when the limits of adaptive response to a stimulus are
exceeded.
▪It is reversible up to a certain point after which the cell recovers
▪Cell death however ensues when the stimulus persists or is severe
enough
Cellular Injury

38. Types of Cell Injury
•Ischaemic/Hypoxic injury
•Toxic/Chemical injury
•Physical injury
•Infective injury
•Genetic injury
•Immunologic injury
•Nutritional injury

39. What determines which cell suffers injury?
•The Type of Cell
•The dose of the injurious agent
•The duration of the injurious assault
•The cell organelle compromised

40. 1. Oxygen deprivation
▪Hypoxia reduces aerobic oxidative respiration
▪Ischaemia causes more rapid & severe injury because it causes both
hypoxia & glucose shortage
▪Causes of hypoxia include cardiorespiratory failure, anaemia, CO
poisoning etc

41. 2. Physical agents
▪Mechanical trauma
▪Extremes of temp. (burns or deep cold)
▪Sudden changes in atmospheric pressure
▪Radiation
▪Electric shock

42. 3. Chemical agents & drugs
a) Some seemingly harmless chemicals can cause injury in high concs
e.g. O
2
,
glucose, salt
b) Some cause injury in little amounts e.g. arsenic, cyanide, mercuric
salts
c) Environmental and air pollutants e.g. insecticides, herbicides
d) Industrial & occupational hazards e.g. CO, asbestos
e) Social stimuli e.g. alcohol, narcotics
f) Other therapeutic drugs

43. 4.Infective agents
e.g. viruses, bacteria, rickettsiae, fungi, parasites etc.
5.Immunologic reactions
e.g. anaphylactic reaction to a foreign protein or drug autoimmune
diseases are also caused by reactions to endogenous self antigens

44. 6.Genetic derangements
▪May cause severe defects e.g. Down’s syndrome or subtle ones
e.g. HbS
▪Inborn errors of metabolism due to enzymatic abnormalities
▪Variations in genetic makeup can influence susceptibility of
cells to injury by chemicals and other environmental insults

45. *Nutritional deficienciese.g.
-Protein energy malnutrition
-Vitamin deficiencies e.g. thiamine def (beri-beri), vit. D def
(rickets), vit. A def (night blindness, xerophthalmia etc)
*Nutritional excessese.g.
-excess of lipids predispose to atherosclerosis
7.Nutritional imbalances

46. MECHANISMS OF CELL INJURY
A number of principles are relevant to most forms of
cell injury
-cellular response to injurious stimuli depends
on the type of injury, its duration, & its severity
-consequences of cell injury depend on the type,
state, & adaptability of the injured cell e.g. cell’s
nutritional & hormonal status & its metabolic
needs

47. Cell injury results from functional & biochemical
abnormalities in one or more of several essential
cellular components
The most important targets of injurious stimuli are
a.)aerobic respiration (mitochondrial oxidative
phosphorylation + ATP production)
b.)integrity of the cell membrane (ess. for ionic
& osmotic homeostasis of cell & organelles)

48. c.) Protein synthesis
d.)the cytoskeleton
e.)integrity of the genetic apparatus of the cell
NOTE-with most stimuli, multiple mechanisms contribute to injury,
and in the case of many injurious stimuli, the actual biochemical locus
of injury remains unknown

49. Depletion of ATP
ATP is a high energy phosphate needed for a couple of cellular
activities which include: membrane transport, protein synthesis,
lipogenesis, deacylation-reacylation reactions for phospholipid turnover
ATP is generated in two ways:
a) Oxidative phosphorylation of ADP (major pathway in
mammalian cells)
b) Glycolytic pathway (generates ATP in the absence of O
2using
glycogen/gluc

50. ATP depletion/ reduced synthesis are frequently associated with both
hypoxic & chemical injuries
EFFECTS OF ATP DEPLETION
These effects manifest with <5%-10% ATP levels of normal cells
Reduced activity of plasma memb. Na pump
Failure of this energy dependent Na
+
,K
+
-ATPase causes Na
+
& H
2O
influx into cells causing swelling & ER dilation

51. •ii.)Failure of ATP dependent Ca
2+
pump causing Ca
2+
influx into cells
•iii.)Increase in anaerobic glycolysis--
(compensatory) . This causes glycogen depletion
lactic acid accumulationpH reduced
cellular enzyme activity.
•iv.)Structural disruption of protein synthetic
apparatus causing detachment of ribosomes from
rough ER + dissociation of polysomes into
monosomes.
•v.)Misfolding of proteins which may culminate in
cell death.

52. ATP depletion effects

53. 2. Mitochondrial damage
Most injurious stimuli target the mitochondria
-Mitochondrial damage causes formation of non-
selective pores in the mitochondrial membrane. This
disrupts memb. potential essential for oxidative
phosphorylation
-Cytochrome c leaks into the cytosol and may trigger
apoptosis

55. 3. Ca
2+
influx and loss of Cahomeostasis
•-Ca
2+
ions are important mediators of cell injury
•-cytosolic Ca
2+
levels are low
•-higher levels are found in extracellular space, mitochondria and ER.
Effects of high cytosolic Ca
2+
levels
•a.)activation of enzymes e.g. -ATPases( cause ATP depletion)

56. -phospholipases (cause memb. damage)
-proteases (cause memb. damage by breaking down
both memb& cytoskeletal proteins
-endonucleases ( cause DNA & chromatin
fragmentation)
b.)increased mitochondrial permeability
c.)induction of apoptosis

57. 4.Accumulation of O
2derived free -radicals
(oxidative stress)
Free radicals are chemical species that have a single unpaired electron in
their outer orbit.
Oxidative stress results from imbalance btwnfree-radical generating &
free-radical scavenging systems
Free-radical generating systems include: a.)absorption of radiant
energy (UV light, X-rays, ﻻ-rays) [ H
2O H
.
+ OH
.
]

58. •b.)enzymatic metabolism of exogenous chemicals or
drugs e.g. CCl
4
CCl
3
.
c.)normal metabolic
redox reactions cause formation of superoxides
O
2+ e-O
2
-
d.)
dismutation of superoxides by superoxide dismutase
(SOD) produces H
2O
2
O
2
-SOD
H
2O
2
e.)epithelial cells, macrophages, neurones
etc generate nitric oxide (NO)

59. Three processes are important in the formation of free radicals
a) Initiation –formation of free radicals as described above
b)Propagation –reaction btwnradicals & non-free radicals
(autocatalytic, self propagating)
c)Termination –this involves different mechanisms
i)spontaneous decay
ii)inactivation by endogenous / exogenous subs called
antioxidants e.g. Vit. E, vit. A, ascorbic acid, glutathione.

60. iii.)by storage & transport proteins (e.g. transferrin,
ferritin, lactoferrin, ceruloplasmin). These proteins bind
Fe & Cu which catalyse free radical formation
iv.)enzymes which act as free-radical scavengers e.g.
--catalase:
2H
2O
2
catalase
O
2+2H
2O --
superoxide dismutase (SOD) 2O
2
-
+ 2H
SOD
H
2O
2+O
2

61. •v.)glutathione peroxidase it
catalyses free radical breakdown e.g.H
2O
2+
2GSH GSSG + 2H
2O OR
2OH
.
+ 2GSH
GSSG +2H
2O
•How free radicals cause cellular injurya.)
lipid peroxidation of membranes --double bonds in
unsaturated fatty acids of memb lipids are attacked by
oxygen-derived free radicals esp. OH
.

62. • b.)oxidative modification of proteins
--free
radicals cause protein-protein disulfide
bonds and oxidation of protein backbone
causing protein fragmentation
• c.)lesions in DNA
--free radicals react with thymine in
nuclear and mitochondrial DNA causing
single-stranded breaks in the DNA

63. 5. Defects in membrane permeability
e.g. plasma membrane, mitoch memb, lysosomal membrane etc
These defects cause loss of selective membrane permeability leading
to
a.)mitochondrial dysfunction-reduced production of phospholipids
b.)loss of memb phospholipids –due to activation of endogenous
phospholipases

64. c)Cytoskeletal abnormalities
Proteases activated by increased cytosolic Ca
2+
cause damage to
cytoskeletal filaments that anchor plasma membrane to the cell interior.
This predisposes cell to stretching
d)Lysosomal membrane damage causes leakage of lysosomal enzymes
e.g. RNAases, DNAases, proteases etc

65. 6. Mechanisms of infective injuryCommon ways
of cellular damage by micro-organisms include:-
contact and entering host cells-release of
toxins -host cell response
may cause additional tissue damage
Mechanisms of viral injury
a.)inhibition of host cell DNA,RNA or protein
synthesis

66. b.)penetration of viral proteins into host cell plasma membrane
causes damage to the integrity of the membrane
c.)lysis of host cells e.g. rabies & polioviruses kill the neurones
d.)manipulation of apoptosis –apoptosis is a host response to
eliminate virus infected cells
e.)damage of cells involved in host antimicrobial defence

67. f.)killing of one cell type may cause death of other cell types that
depend on them e.g. denervation by polio virus causes atrophy of the
muscles concerned
g.)some viruses can cause malignancies e.g. EBV, HBV etc.

68. Mechanisms of bacterial injury
a)virulence –virulence genes encode proteins that
confer this property
b)adherence to host cells e.g.
i) using surface molecule adhesins to bind to host cells
ii) using fimbriae or pili
c)toxins –endotoxins/exotoxins

69. When lethal injury occurs?
When there is lethal injury, the cell dies by either Necrosis or apoptosis.
Apoptosis involves a genetically programmed form of cell death in
which one or few cells dies.
Necrosis is the summative term used to express the sequence of
morphologic changes after cell death in a living tissue.

70. Necrosis versus Apoptosis
Necrosis is accompanied by inflammation but Apoptosis is not
accompanied by Inflammation
Definitive forms of necrosis:
1.Coagulative or structural necrosis
2.Liquefactive or structureless or colliquative necrosis

71. Coagulative Necrosis
Coagulative necrosis is seen in solid organs
such as liver, kidney, testes, ovary, heart,
spleen etc
It is due to protein denaturation

72. Liquefactive necrosis
Liquefactive necrosis is seen in brain and abscesses
It is due to protein digestion such that the structural
details are completely wiped out.

73. Descriptive form of necrosis
•Fat necrosis: seen in enzymatic fat necrosis that occurs in acute
pancreatitis and traumatic fat necrosis in the breast
•Dry gangrene: coagulativenecrosis in the extremities in diabetics. There
s no supervening bacterial infection hence no suppuration

74. Descriptive form of necrosis
•Wet gangrene: coagulative necrosis with supervening bacterial
infection hence there is suppuration. This may be seen at the
extremities of diabetics and in the gastrointestinal tract.
•Caseous necrosis: seen in tuberculosis, fungi infections
•Fibrinoid necrosis: seen in degenerating chorionic villi

75. The Autopsy
•Types
Hospital autopsy
Medicolegal (coroner's) autopsy
•Why carry out autopsies?
➢How was death caused?
➢What was the extent of the disease
➢Medical Audit: Could we have done better?

76. What is the autopsy?
•Autopsy is a highly specialized surgical procedure that is performed
by a pathologist and consists of a thorough examination of a corpse
to determine the cause and manner of death and to evaluate any
disease or injury that may be present (the circumstances of death
with appropriate interpretation.
•The principal aim of an autopsy or post-mortem examinationis to
determine the cause of death, the state of health of the person
before they died, and whether any medical diagnosis and treatment
before death was appropriate.

77. The Autopsy -the word!
•Autopsy as a word has been in use since around the 17
th
century and
is essentially an amalgamation of two words ‘autos’meaning oneself
and ‘opsis’meaning sight or view.
•Synonyms-autopsy is also known as postmortem examination,
necropsy, autopsia cadaverum or obduction

78. Facts about the autopsy
•Reinforces ethical beliefs, convictions and principles of practice
among physicians
•Not part of treatment but statutory service
•May inform better treatment modality
•May inform a better medicare technology
•A universal practice regulated by specific laws

79. Autopsy versus The Law
•Autopsy is a prescription of the law –there are relevant laws –
CORONERS’ LAWS (01/06/1954)
•Nobody is above the law
•The law emphasizes the principle of vicarious liability (seniors bear
FULL responsibility for whatever subordinates do)
•The Law regulates our practice
•Laws are conveyed by rules and regulations set by various councils

80. Manner of Deaths
As Recognised by the law
•Natural causes
•Accident (inadvertent, misadventure or act of God)
•Suicide
•Homicide
•Undetermined
ONLY THE AUTOPSY CAN PROVE ANY OF THESE IN
MOST CASES

81. THE LAW AND THE MEDICAL DISCIPLINES
•Law and medicine are the two oldest professions
•The law recognizes medicine, nursing, pharmacy, physiotherapy and
medical laboratory sciences as unique professional courses.
•The Law is conversant with the schedule of duties of each
professional entity, though there may be considerable overlaps.
•The Law could seek any legal means including the postmortem
examination to determine culpability in clinical negligence.

82. BASIC ASSUMPTIONS OF THE LAW
•You attended an accredited Department with an approved curriculum
•You have basic competence with room for growing competence
•You are registered with a regulatory body (Council)
•You have a current license
•The law recognizes your professional level to assess your practice
•The Hospital Management is responsible for ascertaining current
licensures and regular update of staff through Continuing Medical
Education

83. AUTOPSY-WHAT IT BASICALLY ENTAILS!
•A comprehensive, systematic dissection lasting two and a half to
three hours for the average autopsy.
•Harvesting/Retrieval of organs in isolation or in organ systems to
preserve anatomical relationships
•Systematic interpretation
•Sequential organization of pathophysiological events

84. AUTOPSY-WHAT IT BASICALLY ENTAILS
•Morphology –appearances and changes which may be subtle and
evolutionary (lesions -structural alterations due to the disease
process)
•Colour changes –bile, haemorrhage, melanin
•Shape distortions
•Weights and sizes
•Consistency
•Contents –Haemorrhage, mucin, bile, stones (gall stones, renal
stones)

85. What Morphologies -Possibilities
•Morphology of primary disease process
•Morphology of complications of primary disease process
•Morphology of complications of treatment (iatrogenic)
•Morphology of the predisposing condition
•Morphology of syndromes (strong genetic basis)
•Morphology of incidental findings
•No anatomical cause of death (biochemical deaths, electrocution,
death from some cardiac causes)

86. Types of autopsies
•Routine hospital autopsyas a fall out of routine hospital practice
(clinical or academic autopsies)
•Coroners/medicolegal autopsies
-Hospital coroners
-Police coroners’ cases
N.B. All hospital cases are potential medicolegal cases

87. Types of autopsies?
•Clinical and academic autopsies aim to determine, clarify or confirm
medical diagnosis that remained unknown or obscure prior to
patient’s death; while the coroners’ autopsies aim to ascertain the
cause of death, circumstances leading to death, mechanisms
(pathophysiological phenomenon or events leading to death), manner
of death and identify the deceased.

88. CORONERS CASES.
•Sudden deaths. (including deaths
within 24hrs of admission)
•All Accidental deaths.
•All Suicidal deaths.
•All Homicidal deaths.
•All deaths from Poisoning.
•Industrial Accidents.
•Industrial Disease.
•Deaths in Prison and Police
custody
•Deaths from Abortions
•Deaths in public institutions-
Hostels, Hotels, etc.
•Peri-operative deaths.
•Relatives not satisfied with the
cause of death.
•Deaths arising from medical
negligence/malpractice

89. Medico-legal autopsies in Nigeria
•The coroners system operates in Nigeria
•Magistrate is ex-officio coroner for the district.
•Coroners assisted by the Police Officers.
•Deaths are reported to the Police-Police cases.
•Police investigates and visits the scene.
•Coroner orders the Doctor to perform PM.
•Consent of relatives not required for PM.
•Report is delivered to the police for onward delivery to the DPP
•Relatives get death certificate when appropriate

90. SOME DIFFERENCES
ROUTINE HOSPITAL
AUTOPSIES
MEDICOLEGAL AUTOPSIES
CONSENT YES NO
LIMITSOF AUTOSPY YES DISCRETION OF
PATHOLOGIST
PAYMENT NO YES
POLICE INVOLVEMENT USUALLY NO YES
REPORTING CLINICIAN, MANAGEMENT,
LAW COURT
POLICE
DEATH CERTIFICATION FAMILY -NEXT OF KIN FAMILY -NEXT OF KIN

91. Practical indications for the autopsy
•Instances of the discovery of an unidentified body indicative of foul
play or death in suspicious circumstances such as sudden unexpected
deaths.
•Death of patients not attended to by a physician during the last illness
•Death in patients known to be sick but not seen fourteen days prior
to death

92. Practical indications for the autopsy
•Suicides
•Homicides
•Alcohol ingestion in alcoholics, death from poisons and drug related
deaths in addicts
•Domestic accidents
•Transportation accidents including road, rail, air mishaps and
waterways disasters fall into the category of coroner’s autopsies.

93. Practical indications for the autopsy
•Deaths during surgery, within twenty-four hours of completion of
surgery and before recovery from anaesthetic agents.
•Allegations of negligence by relations during medical treatment. (the
Bolamand Bolitho tests?)
•Death of infants (this does not include hospital deaths in which the
cause of death is confidently known)
•Abortion related deaths
•Deaths in which the cause of death is unknown
•Death of suspects in prison custody

94. Why Patients die
•Malpractice : substandard/suboptimal practice below the standard
expected/accepted in that environment/internationally as expressed
in standard medical literature.
•Malpractice & Clinical Negligence (absolute incompetence, specialty
incompetence, case incompetence.
•Ultimate result of a terminal disease: malignancies, chronic illness

95. WHY PATIENTS DIE
•Inexperienced personnel: Interns (house officer as first on call in
crucial units of Teaching hospitals, unqualified medical personnel in
general/specialist hospitals, inadequate staffing of wards, clinics
?generational gap
•Poor investigation apparatuses(obsolete)
•False laboratory results/ancillary investigations
•Experimental/empirical treatments based on spurious journal
publications

96. WHY PATIENTS DIE
•Atypical presentations can mislead
•Substandard prescriptions due to inexperience, ignorance about
changing trends in clinical care and lack of Departmental policy
•Wrong prescriptions due to misdiagnosis/missed diagnoses (25-40%
false diagnoses)
•Wrong surgeries, poor post-operative follow up

97. Why patients die
•UNDETECTED MEDICAL PROBLEMS
•FAKE DRUGS/IGNORANCE
•POVERTY
•TABOOS, SUPERSTITION: AVERSION FOR CS, PRACTICES OF
TRADOMEDICAL VAGABONDS
•INCONSISTENT, INADEQUATE POWER SUPPLY WITH POSTPONED
SURGERIES (progression of disease process)
•MULTIPLE INDUSTRIAL ACTIONS/STRIKES

98. Patients’ rights (the law’s protection)
•Every patient is a citizen before being a patient
•Every citizen has the right to basic amenities of life which include
good health
•The rights to live should be respected and duly protected even after
death even so when he dies prematurely
•We may need an autopsy to protect this right & probably compensate
the dependants

99. REASONS/BENEFITS OF AUTOPSY
•ESTABLISHING THE CAUSE OF DEATH-Inquisitiveness is the soul of
Pathology
•Determining the manner of death
•Establishing the nature of disease
•Understanding the course of disease
•Research purposes
•Establishing a database: producing accurate
biostatistics/epidemiological data for adequate planning
•For medicolegal reasons cum clarifications
•Harvesting specimens for medical education: instructing medical
students and physicians

100. REASONS/BENEFITS OF AUTOPSY
Medical Auditing
•Comparing antemortem and postmortem diagnoses
•The benefit of the right/proper diagnosis as every patient deserves the
right diagnosis
•Assessing the quality of medical care such as assessment of level of
hospital/professional practice, competence, skills (dexterity) –could we
have done better?
•Identifying new and changing diseases
•Evaluating the effectiveness of investigative apparatuses, therapies,
surgical techniques and prostheses
•Budgeting-RTAs, Emergency care

101. REASONS/BENEFITS OF AUTOPSY
LEGAL BENEFITS
•Monitors public health issues
•Explains sudden unexpected and unexplained deaths
•Can clarify concerns that may otherwise lead to malpractice lawsuits
•Provides information for insurance purposes

102. Benefits for families
•Sense of relieve for relations/loved ones of the deceased.
•Comfort for knowing the cause of death for the sake of posterity thus death is
accepted and foreclosed
•Discovery of hereditable disease
•Reassurance that medical care was adequate and was well supported financially
and otherwise by relations thus guilt is alleviated
•Detection of environmental hazards
•Proper filing of Death certificates/Facilitation of insurance benefits
•Discovery of contagious infection
•Extension of medical knowledge thus healing of ignorance and deletion of myths

103. CASE 1
•Elective induction of labour of the woman (post dated) at a private
hospital, Doctor (Consultant O&G) left the hospital for the nurse only
for his patient to have cardiac arrest
•My colleague wrote a death certificate of amniotic fluid embolism
•Autopsy showed fully formed baby in massive haemoperitoneum with
ruptured uterus
•Died from haemorrhagic shock from uterine rupture due to medical
negligence and malpractice by the physician

104. CASE 2
•The elderly man in prison arrested by the police because he
prevented the police from arresting his relations
•Autopsy showed prostatic cancer with metastasis to the liver
•No marks of violence or torture
•Manner of death –natural illness
•Importance of the PM-Exculpation of the prison wardens

105. CASE 3
•The middle aged man at the quarry who had some heaps of soil
falling on him till he was trapped. He was extricated but died shortly
afterwards.
•Autopsy revealed bilateral adult polycystic kidney disease with
massive intrabdominal haemorrhage (renal bed inclusive) due to
ruptured vessels from compression due to prior elevated
intrabdominal pressure.
•This is an expected occupational hazard/misadventure

106. CASE 4
•The student who on valentine day went to swim at the swimming
pool of a SW University Senior Staff Club and got drowned
•Autopsy showed freshwater drowning, no marks of violence
•Willful search for death -Misadventure
•Other issues –no lifeguard, no life jackets

107. CASE 5
•The nurse (bread winner) in SW Teaching Hospital who had caesarean
section, came back months after with a discharging sinus in the sub-
umbilical scar. Two consultants managed: the O&G and General
Surgeon
•Autopsy revealed –dehydrated woman with a large mass of gauze
forgotten at the time of CS with peritonitis, sepsis.
•Cause of death –Multifactorial (sepsis, GIT obstruction) fluid and
electrolyte imbalance due to forgotten foreign body) a consequence
of medical negligence and malpractice.

108. CASE 6
•A woman (breadwinner) had a CS done, surgeon (SR)noticed
darkening blood conveyed his fears to the nurse anaesthetist who
ordered doctor to mind his business. Baby delivered alive, mother
went to cardiac arrest shortly after baby’s delivery. NA wept like a
baby having realized it was oesophageal intubation rather than airway
intubation
•PM-obstructive atelectasis with cardiopulmonary arrest

109. CASE 7
•Middle aged woman pregnant with 4
th
child drove herself to a SW Teaching
Hospital. Had history of fever, postdated EGA. Induction of labour
commenced. Signs of uterine rupture discovered late. No serious action
taken because labour ward theatre (LWT)was busy. Not moved to
alternative theatre. Eventually action was taken for CS. Pxdied before
incisions in LWT.
•Autopsy revealed fully formed baby within massive haemoperitoneum with
ruptured uterus.
•Cause of death –haemorrhagic shock due to uterine rupture and medical
negligence/malpractice
•Manner of death -manslaughter
•Paradox : wizard of his neighbour

110. CASE 8
•A perimenopausal woman admitted to the casualty in a SWTH with
bleeding per vaginam. Left in the casualty after initial diagnosis of
menstrual irregularities. Found hours after to be in shock later died.
•Autopsy showed massive haemoperitoneum from a ruptured right
fallopian tube ectopic pregnancy
•Cause of death –haemorrhagic shock due to ruptured ectopic
pregnancy and medical negligence/malpractice
•Manner of death -manslaughter

111. CASE 9
•25 yr Female Corper bleeding per vaginam after seven weeks of
amenorrhoea. Physician in a SWS saw in his private hospital and made a
diagnosis of inevitable abortion and evacuated the uterus (D&C) using
Karman’s syringe. No USS done and no uterine specimens were sent for
histology after curettage. She came ten days after the initial presentation;
severely pale and died during examination.
•Autopsy showed right sided fallopian ectopic pregnancy with massive
haemoperitoneum
•Cause of death –haemorrhagic shock due to ruptured ectopic pregnancy
and medical negligence/malpractice
•Manner of death -manslaughter

112. CASE 10
•A middle aged man motorcycle passenger who fell off the
motorcycle. Coroner’s autopsy was requested.
•Autopsy –pyogenic meningitis
•Cause of death –raised intracranial pressure due to pyogenic
meningitis
•Manner of death-natural death
•Not RTA and exoneration of the motorcycle rider

113. CASE 11
•A middle aged man motorcycle passenger who had been ill and was
on treatment at a private hospital fell off the motorcycle. Coroner’s
autopsy was requested.
•Autopsy revealed –Pulmonary Tuberculosis, severe pallor, anaemic
heart failure, hepatomegaly and splenomegaly.

114. CASE 12
•A middle aged man, son of a medical practitioner (medical elder) was
brought to the casualty in SWTH from a hospital in Lagos with a week
history of malaise, fever etc.
•Autopsy revealed –pancreatic mass, vitreous humourglucose level of
> 20.0mmol/litre, acute tubular necrosis

115. CASE 13
•A middle aged man who was shot by armed robbers had surgery and
was later admitted on the ward. He was not fully conscious. Was said
to be gasping and died subsequently.
•Autopsy revealed –gastric contents in the airways indicating
aspiration and poor post-operative care by the team on duty.

116. CASE 14
•A middle aged woman who had a working diagnosis of pulmonary
tuberculosis with pleural effusion. Registrar attempted to do a pleural
tap/aspirate. Patient subsequently deteriorated, was found to be in
shock and died.
•Autopsy revealed –massive left sided haemothorax with compressive
atelectasis of the left lung due to Traumatic laceration of the heart
due to the procedure

117. CASE 15
•A young adult female admitted into the labour ward for IUFD had a
destructive procedure to remove the dead baby.
•Autopsy revealed –severe pallor, traumatic laceration to the female
genital tract and features of shock due to haemorrhage.
•N.B.: Managing Team/Physician was evasive in his documentation of
what happened after the procedure

118. CASE 16
•A SWS Police CID served forms for an autopsy on a young female
adult female whom a medical practitioner claimed collapsed shortly
after she walked into his hospital.
•Autopsy revealed perforation of the posterior wall of the uterus with
severe intrabdominal haemorrhage →Shock →Death
➢Criminal abortion -Doctor liable

119. CASE 17
•The police found the corpse of a young adult female by the road side.
She was supposedly missing for some days. A doctor wrote a death
certificate and the relations buried the corpse. The father protested
to the police who asked for an exhumation. The Doctor was arrested
by the police.
•Exhumation done and autopsy revealed severe pallor, features of
instrumentation, dilated cervix, products of conception
•Haemorrhagic shock from criminal abortion

120. CASE 18
•Middle aged woman in a SWS Teaching Hospital with HBSC had
myomectomy for fibroid. O&G team did myomectomy without the
input of Haematologists. She collapsed a few days after surgery while
returning from the rest room.
•Autopsy showed massive pulmonary embolism with acute right heart
failure.
➢Clinical negligence

121. CASE 19
•A young adult female whose corpse was found in a river having gone
swimming with two male friends. Mother said the male friends killed
her daughter.
•Autopsy showed features of drowning and products of conception,
➢No marks of violence, no strangulation, no features indicative of rape.
➢Misadventure

122. CASE 20
•A young adult male trader was hit on the head with a stone for not
selling shoes at a price agreed by his colleague.
•Autopsy revealed depressed skull fracture with intracranial
haemorrhage.
➢Raised intracranial pressure from severe head injury from blunt
trauma.

123. CASE 21
•A boastful middle aged politician admitted for diarrhoea in a SWS
Teaching Hospital was suddenly found dead on his bed.
•Autopsy showed features of systemic hypertension, dissecting aortic
aneurysm with severe haemorrhage into the pericardial sac
➢Died of Cardiogenic Shock due to cardiac tamponade

124. CASE 22
•A middle aged woman was admitted to a SWS Teaching hospital for
fracture. She was suddenly found passing out frank blood on a
Saturday night and died subsequently.
•Autopsy showed bleeding from ruptured oesophageal varices due to
liver cirrhosis
➢Haemorrhagic shock

125. CASE 23
•A run-away teenager living with two boys was found dead in the
custody of the boys. The boys were arrested and autopsy was
ordered.
•Autopsy revealed features of typhoid enteritis
➢No marks of violence, no strangulation, no features indicative of rape.
➢

126. CASE 24
•Bank manager found dead by his official driver
•Autopsy showed strong smells of bleaching detergent, more in the
stomach
•Death due to severe metabolic acidosis with severe fluid and
electrolyte imbalance
➢Wife later confessed husband has had private conversation
apparently to recover debts from an uncooperative customer.

127. CASE 25
•A middle aged hospital orderly in a SWS Teaching Hospital was
operated for a retroperitoneal mass (supposedly renal mass). Surgeon
was trained as General Surgeon but delved into urology. He
performed the surgery and left and travelled out of town the same
day. SR and Registrar were left to attend to the case.
•Autopsy showed lacerated left kidney, amputated retroperitoneal
mass with severe intra-abdominal haemorrhage. Pxdied of
haemorrhagic shock.

128. CASE 26
•A 28 yr old boxer of SES origin fought for a SWS at National Sports
Festival in Kaduna. He collapsed and died 30 minutes after his bout.
Corpse was embalmed and brought for autopsy in the SWS.
•Autopsy: A severely shrunken cirrhotic liver, splenomegaly with
rupture of the spleen, severe intrabdominal haemorrhage and severe
organ pallor.
➢Deceased was severely and chronically ill before the bout (Chronic
liver disease)
➢The Physician at the Sports Clinic should have picked his problem
via comprehensive medical examination

129. CASE 27
•A middle aged woman was arrested when a boyfriend (younger than
her)was found in a pool of blood in her house. She claimed the
boyfriend stabbed himself.
•Autopsy revealed a laceration on the left side of the neck which
extended into the left pleural cavity with laceration of lung tissue
severe haemothorax and collapse of left lung.
➢No defense marks.
➢Weapon of assault-Kitchen knife in a vulnerable position. Suicide
ruled out

130. CASE 28
•A middle aged senior colleague/lecturer in SWS University who had
visited a Cardiologist for six months complaining of calf pain suddenly
collapsed one day on the corridor in SWS Teaching Hosp.
•Autopsy revealed massive pulmonary embolism, extensive pulmonary
infarcts and subpleural haemorrhages and right heart dilatation
➢Physician culpable –failed to pick the Homan’s sign

131. CASE 29
•A young adult male was hit on the head with a cutlass by a political
thug during the January 2012 fuel crisis in a SWS capital city. He fell
unconscious for a brief moment and recovered. Doctor saw in a
private hospital, sutured the scalp wound and sent home. He died the
third day in his sleep. No skull X-rays, no CT scan, no MRI, no
observatory admission, no follow up
•Autopsy revealed depressed skull fracture with significant epidural
haemorrhage, features of raised ICP
➢Physician practised below acceptable standards.

132. CASE 30
•SARS operatives in a SWS brought corpses of two young adult males
who they claimed were shot when they tried to escape from police
custody.
•Autopsy –close range entry wounds in the front, exit wounds at the
back, massive haemorrhages in chest cavities.
➢Extrajudicial murder

133. CASE 31
•A young adult male was hit on the head while playing snookers in a
village setting on a Sunday. The families “settled in principle” and
buried the corpse overnight. A concerned citizen reported to the
police who ordered exhumation.
•Autopsy revealed intracranial haemorrhage, features of raised
intracranial pressure due to blunt trauma.

134. Yet People Reject Autopsies! -Why?
•Ignorance, wilfulignorance (false education)
•Religious sentiments
•Superstition
•Abuse of the privileges of office
•Corruption/Hypocrisy/double standard (Police, Lawyers, Judges,
Traditional rulers, Politicians, Medical doctors)
•Covering up tracks (malpractice, clinical negligence)

135. Should Postmortem in Nigeria be different from the rest
of the world?
•Medicine is a settled science which did not originate in Nigeria.
•We need to find out while people die so cheaply and easily among us
and while it is not so in developed nations
•We should not accept the status quo
•True schooling should change our outlook and perception of things
then we can really claim to be educated.
•Change the world from your corner

136. Reformation through the autopsy
•The autopsy should generate moral, ethical and
professional questions which we must answer
sincerely; not subject to the whims and caprices
of individuals above the law or based on
sentiments of relationships.

137. Rationale Questions the autopsy should
generate/provoke?
•Why did this patient die? Cause and circumstance?
•Were our clinical deductions compatible with the autopsy findings?
•Was our diagnosis right? Misdiagnosis or Missed Diagnosis
•Why did we miss the diagnosis?
•What facilities for investigations are not available for proper
management?
•What level of doctors and nurses managed, performed surgeries,
procedures, interpreted reports?

138. Conclusion
•Pathology is the bed rock of excellent, legal proof and patient relevant
and treatment responsive clinical practice.
•Diseases are multi-staged events .
•The aetiology, pathogenesis, pathophysiology, anatomical alterations
and functional significance is usually disease specific
•Inflicted structural patterns on tissues correlates with clinical
presentation.
•The cell is the natural habitat of diseases
•The autopsy and autopsy histology help unveil missed diagnoses.

139. End of Presentation
•Thanks for listening
•The Future is Here