A Hidden Culprit: A Report of Two Unusual Deaths Secondary to Gastrointestinal Bleeding

Summary: Gastrointestinal diseases are a significant cause of death, among which bleeding has a high mortality rate, with reported rates ranging from 1% to 20%. We present two unusual cases of exsanguination secondary to gastrointestinal bleeding. Case 1: a 74-year-old female with a history of remote gastric bypass and episodes of hematemesis in the months before her death with no bleeding source identified. Autopsy revealed a 4.3 cm ulcer in the excluded duodenum. Case 2: a 52-year-old male with a history of alcohol misuse, weakness, and pallor, who was found surrounded by minimal bloody material. Autopsy revealed two Mallory-Weiss tears in the gastro-esophageal junction and dilated esophageal varices. Ulceration in the excluded stomach or duodenum in gastric bypass patients can develop months to years after the procedure, potentially representing severe morbidity. A few associated risk factors include the use of steroids or non-steroidal anti-inflammatory medications, lack of buffering effect from the duodenum, presence of bile reflux, reduced bicarbonate secretion from the pancreas, and delayed gastric emptying. Visualization requires alternative methods, such as double-balloon enteroscopy, percutaneous transgastric endoscopy, or surgical exploration. To our knowledge, this is the first report of fatal gastrointestinal bleeding in an excluded duodenum in a gastric bypass patient. Mallory-Weiss tears are longitudinal lacerations of the esophageal mucosa that can result in acute exsanguination and usually occur in male patients with alcohol misuse after a sudden increase in intraesophageal pressure. Rare fatalities have been published. Given the mortality of gastrointestinal bleeding, these cases highlight the importance of a careful evaluation during autopsy. Todd Michael Luckasevic