JOURNAL CLUB:
PROSPECTIVE CROSS SECTIONAL STUDY
April 28th, 2020
Dr. Baishwanar Banerjee
THE ARTICLE
“Bowel wall hemorrhage”: A characteristic sign in
hanging death
A. Okazi MD Assistant Professor, F. Taghaddosinejad, MD
Professsor et al
Journal of Forensic and Legal Medicine
November 5th, 2013
STUDY OUTLINE






Hypothesis: Bowel wall haemorrhage can occur
in hanging
Design: Prospective cross sectional study
Setting: Teheran autopsy hall
Participants: Corpses of hanging victims
Data Collection: Demographic data, autopsy
findings
Outcome: Presence of bowel wall haemorrhage
BACKGROUND
Crime scene evidence, defensive wounds etc
 Commonly designated as suicide
 Number of nonspecific findings
 Nonspecific- can occur after death
 Maxnier (1933) first reported in homicide victims
 Schultz (2011) -12.1%
 Important to rule out other causes

MATERIALS
Autopsied corpses in Teheran from June 2011 to
June 2012
 External examination findings documented
 Internal examination- Subcutaneous
intramuscular neck haemorrhages, injuries to
hyoid bone and thyroid cartilage, Simon’s
haemorrhage and bowel wall haemorrhage
 Exclusion criteria- Abdominal trauma,
coagulopathy, intestinal disease, advanced
putrefaction
 Histopathology examination by forensic
pathologist

METHODS
Samples divided and analyzed into two groups
based on presence of bowel wall hemorrhage.
 Study approved by the ethical committee of
Tehran University of Medical Sciences and
Department of Forensic Medicine. Written
consent was obtained from the family members of
the deceased.
 Data analyzed by SPSS software.
 Frequency and standard deviation were
calculated. T-test and Chi-square test used for
data analysis

RESULTS
118 males (85.5%) , 20 females (14.5%)
 Mean age 35.5 +/- 14.09 years
 Duration between death and autopsy 12-24 hrs in
107 cases (77.5%)
 Complete hanging 61 cases (44.2%)
 Incomplete hanging in 77 cases (55.8%)
 Bowel wall hemorrhage 27 cases (19.6%)-11 cases
in duodenum (37.5%), 8 cases in jejunum
(30.8%),1 case in ascending colon (6.25%), 3 cases
in transverse colon (18.75%), 1 case in both
jejunum and duodenum (6.25%), 1 case in
duodenum and transverse colon (6.25%)

RESULTS (CONTD)
Microscopic confirmation- 16 cases (11.6%)Duodenum 6 cases (37.5%), jejunum 4 cases
(25%),1 case (6.25%) in ascending colon, 3 cases in
transverse colon (18.75%),1 case in duodenum and
jejunum (6.25%),1 case in duodenum and
transverse colon (6.25%)

DISCUSSION
Frequency of bowel wall hemorrhage -11.6%similar to that obtained by Schultz 12.1%
 Larger sample size vis a vis Schultz (138 vs 74)
 Prospective study-contrasted with other previous
retrospective studies
 Exclusion of criteria robust-strengthens study
 Schultz postulated systemic hypertension as
contributing to incidence of bowel wall
hemorrhage-not found in this study
 Future studies- small bowel characteristics like
size, motility. Prolonged suspension may
facilitate haemorrhage by intensifying gravity
effects

CONCLUSIONS/
IMPLICATIONS

After excluding other causes, bowel wall
hemorrhage can be considered as a characteristic
sign of hanging in conjunction with other signs
STRENGTHS
Clinical relevance: Hanging is a commonly encountered case in
the autopsy theatre in most mortuaries in India.
Reproducibility: Can be performed in most medical colleges with a
functioning histopathology unit with the help of pathologists.
Novelty: Not mentioned in standard Indian textbooks of forensic
medicine.
Adequate sample size and statistical analysis using latest
software
Robust exclusion criteria
WEAKNESSES


Judicial hanging cases not considered for study-ethical and
legal restraints
Multicentric studies needed with larger sample size need to
be performed for confirmation of theories